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Twisting of the testes- the Achilles heel of men

In the USA, the annual incidence of testicular torsion is one in 4,000 males younger than 25 years. In testicular torsion, the testes twist (rotate) around the spermatic cord. The spermatic cord is the life line of the testes and carries with it important blood vessels and the duct that carries sperm. When the testis twists around the spermatic cord, the blood supply to the testes is cut off. Within a few hours, the testes can be severely damaged and infertility is a common end result if there is any delay in treatment. Surgery is the mainstay of treatment. Testicular torsion primarily affects teenagers and young adults in the 2nd decade of life, but it can also occur at any age. Males with one or both testicles not descended into scrotum (cryptorchidism) develop testicular torsion more often than the general population. Torsion may occur spontaneously. In about 5-10% of males, it may result from direct trauma to the groin. Other factors that may increase the risk of torsion include an increase in testicular size (volume), presence of a testicular tumor, testis which lies along a horizontal plane, a history of failure of the testes to descend into the groin and a long spermatic cord. Torsion often occurs during sleep.
 
What happens during testicular torsion? When torsion occurs the testes rotates along the spermatic cord. During the rotation, it obstructs the blood flow. The stoppage in blood flow results in ischemia and no oxygen supply to the testes. The degree of damage to the testes depends on the duration of the torsion and the degree of twisting of the spermatic cord. Changes are evident in the testes soon after torsion and are reversible up to 4 hours. However, after 24 hours of torsion, the testes is almost always non functional and salvage is impossible.
 
Differential Diagnosis Testicular torsion is a surgical emergency and if there is going to be any hope of salvage; it must be rapidly diagnosed and treated. Any delay in the diagnosis almost always leads to loss in the testes. Over diagnosis of the condition leads to unnecessary surgery. Data from hospital records indicate that testicular pain is quite frequent in teenagers and young adults. At least 20-40% of young males complain of some type of testicular pain at some point. Conditions which can mimic testicular torsion include: - trauma to the scrotum - epididymitis (infection of the spermatic cord) - orchitis (infection of the testis) - incarcerated hernia - varicocele - idiopathic scrotal edema - torsion of the appendix testis Whenever there is trauma to the groin area, there is a general tendency to always attribute the scrotal pain entirely to trauma and become oblivious to the presence of testicular torsion. However, if the pain lasts more than one hour after the trauma, the testicle should always be evaluated for possible trauma-induced torsion.
 
Signs and Symptoms Symptoms of testicular torsion include: - Blood in semen - Pain in the groin and lower abdomen - Hard testicle and redden testicle - Swelling of the testicle - Nausea and vomiting - Sudden, severe testicular pain Clinical Examination When an individual presents with testicular torsion, pain is a common feature. The patient may not allow the examiner to touch the testes because of the pain. The spermatic cord is shortened because it is twisted and the testes may be higher compared to the unaffected testes. This finding of an elevated testes is quite specific and provides strong evidence for testicular torsion. The affected testes will also appear swollen and engorged. Another important finding which may provide a clue to the diagnosis of testicular torsion is the absence of what is called the cremasteric reflex. This reflex is elicited by stroking or pinching the skin on the medial thigh, causing contraction of the cremasteric muscle, which elevates the testis. The cremasteric reflex is considered positive if the testicle moves at least 5 mm. This reflex is almost always present in healthy young males and the loss of the cremasteric reflex is at least 99% sensitive for testicular torsion. Diagnostic tests Despite all the physical signs and clinical acumen of the physician, most doctors order some type of radiological test to confirm the diagnosis of testicular torsion. Only in the rare exceptional cases, where the diagnosis is unequivocal is surgery done without further studies. In all cases where the diagnosis is in doubt, diagnostic testing is highly recommended. The most commonly used radiological tests to asses the scrotum are Doppler ultrasonography, radionuclide imaging, and surgical exploration. Ultrasound Blood flow in the testes can easily be evaluated by ultrasound. In patients with testicular torsion, the blood flow in the affected testis is decreased or absent compared with the asymptomatic testis. In addition, the affected testicle appears to be enlarged. Initially, the testicle may also reveal increased echogenicity once the testes is infarcted and starts to die. Doppler ultrasonography also can differentiate between ischemia of the testes and inflammation of the epididymis. Ultrasound also can reveal the presence of other testicular disease (e.g., torsion, tumor, hydrocele, hematoma, and varicocele). In some cases, the Doppler ultrasound can miss the diagnosis of testicular torsion, especially when the torsion is only partial. In addition, the technique can also show falsely suggest testicular torsion, when none is present. This is particularly so in younger teenagers and children with smaller prepubescent testicle. Doppler ultrasonography is not 100% sensitive for testicular torsion.
 
Radionuclide study Radionuclide studies are 100% sensitive for the diagnosis of testicular torsion. Individuals with suspected torsion are injected with a small amount of a radioactive chemical which flows into the blood vessels. When the blood flow to the testes is obstructed, the radionuclide will not show up in the testes. In cases of inflammation or infection, there is more flow of the tracer to the testis. Radionuclide study is the gold standard and 100% sensitive for the diagnosis of torsion. However, the test is not always readily available and does take a few hours to perform. In contrast, ultrasonography is faster and more readily available. This is important to know when dealing with testicular torsion- a condition that depends on rapid diagnosis for a positive outcome.
 
Treatment The treatment of testicular torsion is surgery and thus as soon as the diagnosis is confirmed the patient must be referred to a urologist for prompt surgery. Time is of essence and viability of the testes is highly dependent on prompt detorsion.
 
Manual detorsion Manual detorsion is sometimes used to treat testicular torsion. However, this must only be done by the surgeon. The patient usually requires some form of IV sedation and also injection of a local anesthetic in the scrotum near the spermatic cord. The physician will manipulate the testes and try to rotate the testes into its original position. This is easier said than done. Frequently there is more than 360 degree of torsion and it is impossible to know how many turns to make for detorsion. After every manual detorsion, return of blood flow must be documented by ultrasound. Even if the detorsion is successful, elective surgery must be done to permanently repair the defect so that torsion does not recur. A number of times this manual detorsion attempt fail and frequently the situation worsens. Most urologists prefer to take the patient straight to the operating room instead of mucking around blindly with a serious condition. When successful, manual detorsion results in immediate relief of pain. Data from some series reveal a success rate of only 20% and in some cases there has been an 80% success rate (more based on luck than any technical skill). The surgeon should never persist and be obsessive about manual detorsion. If it fails, the patient should be hurried to surgery. Only surgery can provide the definite treatment. In addition, given the risks of a missed diagnosis, scrotal exploration may be needed if a definitive diagnosis cannot be made. If the testicle is not viable, it must be removed. In many cases, when torsion of the testes occurs on one side, it is very likely that the same anatomical defect occurs on the other side and thus, most urologists will also fix the other testes to prevent future torsion.
 
Postoperative surgery In individuals who required complete removal of the testis because of non viability, a testicular prosthesis is available. This can be placed in the scrotum at around 3-6 months, once healing is complete.
 
Legal implications Law suits are quite common when it comes to the testes. No one is happy to lose their testes. Any evidence of a missed or delayed diagnosis is a sure bet that a law suit may result. There may be a risk of litigation even if the patient has delayed seeking medical attention. Any time there is a poor outcome, the probability of a lawsuit is real.
 
Summary The most significant and feared complication of testicular torsion is loss of the testis, which may lead to permanent infertility. Common causes of testicular loss after torsion are a delay in seeking medical attention, incorrect initial diagnosis and delay in treatment of the condition. Testicular torsion is one of the few emergencies in urologic practice. Any delay in the diagnosis by more than 4-8 hours severely reduces the chances of salvaging the testes. Some surgeons claim that there is a direct correlation between the duration of torsion and abnormal semen findings. Some authorities even suggest that retention of an injured testis can induce pathologic changes to the contralateral testis. This creates a major dilemma when evaluating patients who present to the surgeon late. Removing one testis is fine; removing two testes is a nightmare-for both the surgeon and the patient.
 
Table 1: Clinical practice guidelines for testicular torsion - obtain a quick history and physical examination of a patient with acute scrotal - Pain should include evaluation of the testicular lie and cremasteric reflex - Either Doppler ultrasonography or scintigraphy can be the initial diagnostic study. Physicians should order whichever test is faster and more readily available at their institution. - Any patient with a history and physical examination results suspicious for torsion should have surgery immediately. - Manual detorsion provides quick and noninvasive treatment. Return of blood flow should be documented - Subsequent elective orchiopexy is recommended.
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