Testicular torsion as a surgical emergency
Testicular torsion is the testis twisting on its spermatic cord (blood vessels, nerves and the vas deferens, the tube that carries sperm), which cuts off its blood supply.
Remember
Treat suspected testicular torsion as a surgical emergency: irreversible damage can occur after about 6 hours, so the patient goes to theatre without waiting for imaging or a trial of antibiotics.
Memory aid
Like a kinked hosepipe, the longer the cord stays twisted, the more tissue is lost.
Picture a kinked hosepipe whenever you think of how a delay in untwisting the cord costs testicular tissue.
In testicular torsion the testis rotates on its spermatic cord. The veins, which have thin walls, are squeezed first, so blood cannot leave and the testis swells. Then the arteries are compressed, so blood cannot arrive. The tissue becomes ischaemic (starved of oxygen) and, if the twist is not released in time, necrotic (dead).
The usual picture is sudden, severe, constant pain on one side, often with nausea and lower abdominal pain, in a young male. Torsion is most common between 12 and 18 years. On examination the testis may be high-riding (raised in the scrotum) and may lie transversely (sideways), and it is tender. The cremasteric reflex (the testis lifting when the inner thigh is stroked) may be absent.
Irreversible damage can occur after about 6 hours, and the clock starts when the pain starts, not when the patient reaches hospital. Torsion is a clinical diagnosis, so a suspected case needs emergency surgical exploration without waiting for imaging.
At operation the surgeon untwists the cord (detorsion) and fixes both testes in place with stitches (bilateral orchidopexy). Both sides are fixed because the loose attachment that lets a testis swing and twist can be present on both sides. A testis is removed only if it is already necrotic.
Key facts
- Time window
- irreversible damage can occur after about 6 hours, and surgical repair is ideally done within 6 hours.
- Diagnosis
- torsion is a clinical diagnosis, so imaging should not delay surgery when torsion is strongly suspected.
- Typical patient
- sudden, severe, constant one-sided pain, often with nausea, in a young male; most common between 12 and 18 years.
- Examination
- a tender testis that may be high-riding, with a cremasteric reflex that may be absent.
- Operation
- untwist the cord and fix both testes in place, and remove a testis only if it is already necrotic.
- Risk factor
- a poorly anchored testis, the bell-clapper deformity (it hangs freely like the clapper inside a bell and can spin), makes torsion more likely.
Exam traps
- Waiting for a Doppler ultrasound (a scan that shows blood flow) to confirm the diagnosis is a trap, because when torsion is strongly suspected on clinical grounds, waiting for imaging delays treatment and can cost the testis.
- Antibiotics for presumed epididymo-orchitis (inflammation of the epididymis, the coiled tube behind the testis, and the testis itself) do nothing for a twisted cord, and a high-riding testis with nausea points to torsion instead.
- Fixing the affected testis only leaves the other testis unfixed, because the loose attachment that lets a testis swing and twist can be present on both sides, so the testis left unfixed is not protected against torsion.
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