Testicular torsion occurs when the spermatic cord that supports the testicles in the scrotum twists, cutting off blood flow. It typically happens during sleep or after strenuous physical activity and must be evaluated and treated immediately. Without immediate medical attention, the testicle could die from lack of blood supply within six hours.
Symptoms
Testicular torsion is a life-threatening emergency in which the testicles rotate around the spermatic cord that supplies blood. If not treated immediately, the lack of blood flow can destroy the testicle within hours. It is a urological condition that most often occurs during male puberty.
It may be caused by rough physical activity, a hit to the groin or even while sleeping. Adolescents are especially susceptible to this medical emergency because they have bell-clapper anatomy, meaning that their testicles spin freely in the scrotum and easily spin out of place. Symptoms of torsion usually occur within a few hours of the injury. They include severe pain in the scrotum, swelling and sometimes vomiting.
If left untreated, a twisted testicle can lead to infertility and the death of the testicle. However, a timely de-torsion procedure can save the affected testicle and prevent the permanent loss of fertility.
A diagnosis of torsion depends on a prompt clinical assessment and a scrotal exploration. A doctor should always assume that the cause of a sudden and severe scrotal pain is torsion until proven otherwise.
UK guidelines suggest that the diagnosis of torsion should be made by a urologist with a rapid physical examination and scrotal ultrasound, which can be used to evaluate blood flow. However, the use of Doppler ultrasound is associated with a high false-negative rate in prepubertal patients and persistent arterial flow does not exclude testicular torsion.
Despite the seriousness of the condition, too many boys and young men are delayed in seeking medical attention when they experience symptoms. As a result, the rate of fatalities has increased significantly. In mid- and south Essex alone, more than one boy or young man loses a testicle each month due to delayed treatment.
In addition to advising anyone who experiences a twisted testicle to seek immediate medical care, parents should make sure that school or sports coaches and other caregivers know about the signs of testicular torsion so they can alert parents. This can help to reduce the number of cases that are missed and the need for adolescent boys to be admitted to hospital in the critical early stages of the condition.
Diagnosis
If your son has experienced a sudden painful scrotal swelling, he needs to be seen urgently by a urologist to assess the possibility of testicular torsion. This is a medical emergency and should be treated within 6 hours to reduce the chance of permanent damage. Diagnosis can usually be made by a prompt history and physical examination. A scrotal ultrasound (USG) scan may be needed to see the blood flow in the testis and spermatic cord.
The onset of pain is typically sudden and severe, often occurring during sports or physical activity. The pain is normally accompanied by nausea and vomiting, and the scrotum may become red and bloated. Sometimes the edema of the scrotum spreads to the lower abdomen or the groin. There may also be a previous history of short-lived episodes of pain that have resolved spontaneously.
A urologist will examine the scrotum for signs of sudden enlargement, redness, and tenderness. The scrotum should also be examined for absence of the cremasteric reflex, which is an important sign of the presence of the spermatic cord and testicular blood flow. The urologist will also feel the scrotum for a “brick-like” texture, which indicates that the spermatic cord has not twisted and is still attached to the testicle.
In cases where the urologist is unsure of the diagnosis, a Gram stain of a sample from the scrotum may be required to confirm the suspected bacterial infection and distinguish between epididymitis and testicular torsion. USG of the acute scrotum is recommended as it provides a high level of diagnostic accuracy. However, UK guidelines state that imaging studies should not be performed unless a scrotal exploration is strongly suggested by history and physical examination as they will delay the investigation and potentially prolong ischaemia of the affected testicle.
If a boy or man has been diagnosed with testicular torsion, the surgeon will remove the affected testicle and attach it to the other side of the scrotum with a surgical procedure known as orchidopexy. The surgeon will also tether the unaffected testicle to prevent re-torsion in future.
Treatment
Testicular torsion is a time-sensitive emergency that must be diagnosed quickly to prevent permanent damage or loss of the testicle. Symptoms include sudden pain in the testicle and a change in color or appearance of the scrotum. Prompt treatment is necessary because if the flow of blood to the testicle is cut off for too long, it will die. Typically, this happens when the spermatic cord twists cutting off the testicle’s blood supply. It usually occurs in infants or teenagers and is a common condition during male puberty.
Testicle torsion can occur from injury or strenuous physical activity, but it can also happen spontaneously. If you or your child experiences symptoms of testicular torsion, see a urologist right away. A urologist can assess the situation and determine if there is a chance that the testicle can be saved.
To diagnose testicular torsion, a urologist at Pristyn Care will perform a rapid clinical evaluation including an examination of the scrotum. He or she will check the color, shape and texture of the scrotum as well as the presence of the cremasteric reflex. If the scrotum is red and tender and there is no cremasteric reflex, it is likely that testicular torsion has occurred. A scrotal ultrasound can also be used to evaluate the status of the testicle and the presence or absence of blood flow to the testicle.
If a urologist suspects that testicular torsion has occurred, it is crucial that surgery be done immediately to restore the flow of blood to the testicle. If the surgery is performed within 6 hours of the onset of symptoms, the testicle can be saved almost 100% of the time. If surgery is delayed, it can cause permanent loss of the testicle and infertility.
During the surgical procedure, the urologist will untwist the spermatic cord and the twisted testicle to restore its blood flow. He or she will then secure the testicle to the inner scrotal wall with a procedure called orchiopexy. This is usually done on both testicles to prevent future torsion. If the testicle has been irreparably damaged due to prolonged lack of blood flow, it may need to be surgically removed (orchiectomy). The contralateral (opposite) testicle is fixed in place as well to prevent torsion on the opposite side.
Recovery
Men who experience severe testicular pain that doesn’t ease with ice or over-the-counter care should seek emergency medical attention. Testicular torsion is one of those rare emergencies where time is the single most important variable in terms of preserving testicular tissue: the longer the testicle’s blood supply is cut off, the less of the tissue can be saved.
A physical exam and imaging tests (including an ultrasound with Doppler flow) are needed to confirm the diagnosis. The testicle will be evaluated for tenderness, swelling, and abnormal positioning. Blood and urine tests are also commonly performed to check for infections.
When the testicle’s spermatic cord becomes untwisted, it’s fixed inside the scrotum to prevent future episodes of torsion; in extreme cases, surgery is done to remove the affected testicle. Most patients are able to resume sexual activity one to two weeks post-surgery.
In some cases, the twist may release briefly and relieve pain. Although this is a relief, anyone with this type of pain should still walk into ER of Watauga or call 911, as the underlying anatomy hasn’t changed. Delaying treatment can result in permanent loss of the testicle and permanent infertility. It’s critical to seek care immediately for testicular pain that doesn’t resolve with ice or over-the-counter medications.