Men experiencing testicular torsion require immediate medical care as the condition can lead to irreparable damage in its presence or misdiagnosis, particularly if delayed diagnosis.
Patients typically report sudden, intense pain on one side of the scrotum (the pouch where testicles hang). Sometimes one of their testicles has decreased blood flow and appears hypoechoic with Doppler ultrasound imaging.
Causes
Testicular torsion occurs when the spermatic cord, which supplies blood to testicles, twists inside the scrotum and cuts off its supply, leading to testicle death without immediate treatment. Testicular torsion should be considered a medical emergency and treated within six hours of its onset as after this point lasting damage may ensue leading to decreased fertility or reduced sperm count resulting in permanent infertility or diminished fertility rates.
Testicular torsion occurs most commonly to one testicle at a time; most commonly the left one. This condition is more prevalent among boys and young men and may be caused by congenital abnormalities like bell clapper deformity, injuries to testicles/scrotum/trauma, undiagnosed hernia/epididymitis/scrotal hematoma etc.
Torsion pain can be intensely, sudden and persistent. It tends to affect one side of the body at once and tends to be significantly worse than any other health issues. The pain can range from sharp and throbbing, burning or aching sensations; infected testicles often appear swollen and redder in comparison with their white counterparts; some patients can experience nausea and vomiting as a result of torsion pain.
Ultrasound with Doppler flow is the diagnostic tool of choice in emergency departments to diagnose testicular torsion. This allows doctors to compare an asymptomatic testicle with its painful counterpart and spot signs of torsion within the spermatic cord, evidenced by twisting. A urologist will then need to perform surgery in order to untwist it and restore blood flow.
Orchiopexy, or untwisting of the cord, is usually performed in an operating room setting by a surgeon. If, however, torsion occurred in an unusual direction (say towards the back), manual unwinding can become impossible and surgery will likely still be required to untwist it completely.
Following surgery, the urologist will stitch both testicles together as well as place stitches in the scrotum to prevent further torsion episodes. Some patients will require repeat orchiopexy once their testicles have healed and their spermatic cord has rejoined with their body.
Symptoms
Human beings are one of the most complex and resilient organisms on Earth; yet we can still be plagued with serious conditions that impair our muscles. Torsion dystonia is one such disease which causes muscles to contract unnaturally and causes various symptoms depending on its type and severity.
Idiopathic torsion dystonia is the most prevalent form of dystonia and affects people of any age. It is caused by dysfunction of the basal ganglia, a group of brain cells responsible for movement control. While symptoms may appear anywhere on the body, typically occurring in the head and neck region with symptoms including turning, tilting or tilting motions; some individuals also report muscle spasms in arms or legs.
Traumatic Idiopathic Torsion Dystonia occurs when testicles become misalign and twist around the spermatic cord, cutting off blood flow to one or both testicles and potentially leading to lasting damage. Seeking medical assistance immediately should you suspect this condition, since any lasting damage could result.
Testicular torsion occurs when tissue surrounding a boy’s testicles and the spermatic cord twist around each other, cutting off its blood supply and eventually killing off one or both testicles within hours. Symptoms of testicular torsion may include sudden, severe pain in one testicle; swelling of the scrotum; one higher than another testicle; and lack of blood flow on ultrasound scan.
Some patients may require surgery to untwist their spermatic cord and restore blood flow, although in certain instances a urologist may be able to untwist it within hours in an emergency room setting. If their bodies have been inexorably bent for over eight hours, however, then an orchidectomy (the removal of testicles) will likely be necessary in order to avoid permanent damage to organs such as testicles.
Torsion dystonia may be caused by medications or conditions, including anorexia and diabetes. When there is no known cause, botulinum toxin injections are an effective solution, weakening muscles to reduce involuntary contractions and contractures. Children suffering from idiopathic torsion dystonia also often find relief through taking dopamine-enhancing medication.
Diagnosis
Symptoms of torsion should be evaluated when sudden, intense pain in either testicle occurs suddenly. These typically include an enlarged testicle with decreased blood flow compared to its opposite side and possibly twisted spermatic cord. Ultrasound should be performed at once in an emergency department in order to confirm this diagnosis and enable urologists to distinguish it from epididymitis and hernias which present with similar symptoms.
Healthcare providers use multiple diagnostic tests, in addition to physical examination and scrotal ultrasound, to assess whether their patient has torsion. These include urinalysis and color Doppler ultrasound of the scrotal sac to measure blood flow; additionally urologists will look out for signs such as an appendix testis that has turned blue due to an accumulation of cyanotic fluid under the sac – this characteristic feature of torsion can be recognized through its appearance; pathognomonic signs include testis inflection of torsion can indicate severe forms.
Urologists will inquire into any history of trauma to the testicles, associated nausea or vomiting and when pain first appeared. Furthermore, they want to know whether the testicle was elevated after injury and whether pain is constant or intermittent.
Urologists will perform surgery to untwist and restore blood flow as quickly as possible; testicles only survive six hours without blood, so if torsion occurs within this window of time it can often be salvaged. However, if torsion is not detected promptly and removed (an “orchiectomy”) immediately in order to avoid permanent damage and infertility. Boys who have their testicles removed can still become biological parents when they reach adulthood, though their sperm count will likely be considerably reduced. It is best for these patients not to engage in sexual activity until advised by a healthcare provider; many opt for receiving an artificial testicle later in life in order to feel more masculine and boost their self-image.
Treatment
Testicular torsion is a medical emergency and should be addressed quickly in order to minimize risk and damage to the spermatic cord. A urologist must untwist and de-torsion the cord in order to restore blood flow – this can be accomplished quickly in the emergency room setting. A biopsy may also be required in order to assess any permanent damage; in any event urinalysis and ultrasound with Doppler flow should also be completed for evaluation purposes.
Urologists should be consulted immediately if a patient experiences symptoms indicative of testicular torsion: sudden pain in one testicle, diffuse swelling and tenderness in the scrotum and loss of cremasteric reflex. An ultrasound can be used to view whether or not one or both testicles has become twisted towards or away from midline; most torsion are usually towards midline; however some may twist in an opposite direction.
Note that most patients diagnosed with testicular torsion will ultimately require orchiectomy (surgery to remove the affected testicle), typically within six hours to prevent lasting damage to spermatic cord. In certain situations, manual detorsion may also help restore blood flow.
Rodent models have been used to evaluate various pharmacologic agents used to attenuate or decrease reperfusion injury following detorsion of the testicle, such as ibuprofen, melatonin, acetylcysteine, oxytocin, propofol and tadalafil; most common among them include ibuprofen, melatonin, acetylcysteine oxytocin propofol and tadalafil. Most studies measure oxidative markers like tissue malondialdehyde and glutathione markers; most indicate that treatment decreases this change to various degrees compared to its pre-torsion levels; most studies indicate pharmacologic agents do indeed decrease this change to various degrees when tested against their pre-torsion levels when given doses.
Analgesics and antianxiety medications are invaluable tools in treating torsion, providing patient comfort while aiding pulmonary toilet and physical therapy regimens. Antiemetics may also be necessary in cases of nausea; these drugs are typically available at hospitals as oral or injectable medication. It is highly advised that individuals at high risk for torsion (such as young, athletic males) consult their urologist about using anticoagulants as preventive medicine; particularly relevant when discussing future surgery for torsion (such as male athletes at risk for future torsion).
