Testicular torsion is a condition wherein the spermatic cord that provides blood supply to the testicle is twisted, resulting in the blood supply to the testis being cut off. The condition is most common in young adolescent boys between the ages of 12 and 18. Very rarely it is seen after the age of 30. Among neonates, the condition may develop prenatally or postanatally and is one of the causes of congenital monarchism. Although some men may be genetically and/or anatomically pre-disposed to the condition, it may also result from trauma to the scrotum, temperature fluctuations, or after strenuous exercise. Torsion primarily occurs from an incomplete attachment of the testes within the scrotum. Males who notice either one or both of their testicles to be able to rotate freely within the scrotum are at higher risk of developing torsion. Symptoms of testicular torsion include sudden onset of severe pain in one testicle, scrotal swelling, nausea, giddiness, and occasionally, fever. Unlike epididymitis, elevation of the scrotum does not reduce the pain in the case of testicular torsion.
The most efficient way to diagnose testicular torsion is by a Doppler sonography of the scrotum to identify the presence or absence of blood flow to the testicle. It is important to diagnose the condition immediately after the onset of symptoms, since testicular viability may be compromised. If corrective action is not taken within six hours after the onset of the symptoms, the chance of testicular salvage is reduced drastically. A simple surgery, which involves untwisting of the spermatic cord and a permanent suturing of the testicle to the inner lining of the scrotum is all that is need as a corrective measure. In most cases, the non-affected testis is also sutured, to prevent any risk of a similar torsion in the future. In case the testicle is dead due to prolonged testicular torsion, it must be removed to prevent gangrenous infection.
Al-Marzooq et al. (2003) undertook a retrospective study of medical records of all patients younger than 16 years of age who presented with acute scrotum during a ten-year span. A total of 123 patients were studied. In 87 of these patients, scrotal exploration was performed and 25 (20.3%) were found to have testicular torsion. Doppler ultrasound examination was performed in 41 (33.3%) of the patients and 11 of them showed doubtful results. They underwent scrotal exploration and testicular torsion was detected in six of them. Testicular torsion was found to be significantly associated with pain in all the cases. The pain was of abrupt onset in 93.8% and of a persistent nature in 94.1% of the cases. Other signs associated with the condition included generalized testicular tenderness, unilateral swelling, and absent cremastric reflex, present in all the diagnosed individuals, and swelling on examination (92%), testicular retraction (87.5%), skin changes (75%), cord tenderness (75%), and cord thickness (70%).
[Al-Mazrooq RH, Al-Rayes AAN, Altawash FM. Paediatric testicular torsion-Clinical evaluation and role of Doppler ultrasound. Bahrain Med Bull. 2003: 25(4):153-5.]
Al-Salem (1999) reviewed the incidence and treatment of intra-uterine torsion of the testis in five newborns treated for unilateral torsion of the testis between 1988 and 1997. In all except one child, the affected testis was enlarged, firm to hard, tender, the overlying skin dark red and the affected testis higher than the contralateral testis. In one child the right testis was enlarged and higher, but soft to firm, and the overlying skin was oedematous and red. The exploration revealed extravaginal torsion of the testis which was gangrenous in four; in one after detorsion there was hemorrhage and hematoma of the cord and the tunica, and the testis was slightly congested but not gangrenous. This testis was preserved and bilateral orchidopexies performed; at 18 months both testes are palpable and of normal size. In the remaining four children the testes were frankly necrotic; they underwent orchidectomy and contralateral orchidopexy. Histology in all four revealed a totally infarcted testis with extensive hemorrhage and vascular congestion.