Torsio Testis2016
Torsio Testis2016
Torsio Testis2016
The acute scrotum is a challenging condition for the treating wary of younger males presenting with the acute
emergency physician requiring consideration of a number of scrotum. European Journal of Emergency Medicine
possible diagnoses including testicular torsion. Prompt 23:160–165 Copyright © 2016 Wolters Kluwer Health, Inc.
recognition of torsion and exclusion of other causes may All rights reserved.
lead to organ salvage, avoiding the devastating functional European Journal of Emergency Medicine 2016, 23:160–165
and psychological issues of testicular loss and minimizing
unnecessary exploratory surgeries. This review aims to Keywords: acute, pain, review, scrotal, testicular, torsion
and possible future roles of labwork and radiological Received 1 April 2015 Accepted 6 July 2015
imaging in diagnosis. Emergency departments should be
Torsion of the testis is a common condition that accounts Table 1 Age distribution of the causes of an acute scrotum seen at
for ∼ 20% of paediatric patients presenting to the emer- surgical exploration [3]
gency department with acute scrotal pain, with torsion of Age group Testicular torsion Torted appendix Epididymo-orchitis
the testicular appendix representing the most common (years) (%) testis (%) (%)
Henoch–Schonlein purpura and communicating haema- In the majority of cases, rotation of the testes initially
toceles following abdominal trauma [7,8]. compromises venous return. However, as time progresses
and oedema ensues, arterial flow is reduced or occluded
Age of presentation can vary, but the age at which boys
[14]. Although the majority of TT occurs in a medial
are most commonly affected with TT is between 12 and
direction, several studies have shown torsion in a lateral
18 years, with a peak between 13 and 16 years [1,5,9]. In
direction in up to 29–33% of cases [9,16].
a retrospective analysis of 115 boys with an acute scro-
tum, of the 83 patients with TT, only 7% occurred in The degree of testicular rotation varies according to the
boys under the age of 11 years [10]. Other series of the literature. One retrospective study of 200 paediatric boys
acute scrotum show a peak incidence of torsion of the with TT showed a higher degree of rotation in non-
testicular appendix of around 10–11 years of age [1,3]. salvageable (managed with orchidectomy) versus sal-
vageable testes (median 540 vs. 360°) [9]. However, the
authors also noted that testicular infarction can occur with
Anatomy and mechanism of infarction rotation as mild as 180°.
TT can occur in several different ways, and can be
TAT results in infarction of the mesothelial remnant of
classified as intravaginal, extravaginal or mesorchial. A
the Müllerian (paramesonephric) duct on the super-
slight preponderance in left-sided TT has been noted in
olateral surface of the testis. The appendix of the epidi-
some series, although the mechanism for this is unclear
dymis (remnant of mesonephric duct) has also been
[1,9,11].
reported to twist [17]. This results in a hard mass on the
Intravaginal torsion most often occurs because of a con- surface of the testicle with point tenderness and a ‘blue
genital malformation of the processus vaginalis as the dot’ sign (a subtle blue-coloured mass viewed through
testis descends into the scrotal sac. This type of torsion the scrotal skin on examination). TAT occurs more
accounts for the majority of TTs, and is most often seen commonly in the prepubertal age group [3].
in pubertal boys, where rapid growth and increased vas-
culature may be a precursor. Under normal circum-
Diagnosis
stances, the tunica vaginalis does not fully extend around
History
the testicle and attaches to the posterolateral scrotal wall,
A careful assessment of history is vital in the assessment
allowing the testis to remain suspended in an upright
of the acute scrotum. The classical presentation for TT is
vertical position. However, in up to 12% of boys, the
sudden-onset severe unilateral pain. The pain, being
tunica vaginalis completely envelopes the testis and
ischaemic in nature, typically requires opiate analgesia.
epididymis, resulting in a ‘bell-clapper’ testicle that is
Persistent pain after opiate analgesia should lead to sus-
more horizontally oriented, with greater ability to rotate
picion of TT. The pain may be accompanied by a history
freely around an axis [12].
of previous bouts of intermittent testicular pain, which
Extravaginal torsion, which is rare, occurs during the likely represents episodes of torsion and detorsion.
perinatal period and is because of a different mechanism.
The duration of symptoms before presentation can vary
It occurs during descent of the testes into the scrotum
significantly, ranging from several hours to several days.
before scrotal investment of the tunica vaginalis has
However, patients with TT tend to have a shorter
taken place, where complete adhesion to the surrounding
duration of symptoms before presentation [1,18]. Early
tissues is usually completed by 6 weeks of age [13].
presentation in cases of TT is associated with higher
Twisting of the processus vaginalis and its contents
likelihood of salvage.
results in necrosis and absence of blood flow within the
testis, epididymis and cord. If torsion has occurred in the The presence of nausea and vomiting, caused by reflex
prenatal period, the clinical presentation is a neonate stimulation of the coeliac ganglion, can be a useful clue in
with unilateral or bilateral blue nontender hard masses in diagnosing TT, but incidence varies significantly in the
the scrotum [14]. However, if it occurs in the postnatal literature. Some series report nausea and vomiting in
period, the presentation is more classic, with acute 57–69% of patients with TT, with positive predictive
inflammation and erythema in a previously normal neo- values for nausea and vomiting as high as 96 and 98%,
natal scrotum, requiring exploration and fixation [13]. respectively, compared with 8 and 4% in TAT and none
in epididymo-orchitis [9,10]. Other series have shown
Mesorchial torsion is exceedingly rare and has an atypical
that nausea and vomiting do occur in torsion of the tes-
presentation. It occurs because of anomalies in the
ticular appendix and epididymo-orchitis, but the com-
mesothelium that covers the anterior half of the testis and
plaint is much rarer [1,18].
suspends it from the vasculature and epididymis. When
the attachment is narrow, mesorchial torsion can occur Dysuria is an uncommon complaint in TT, and its pre-
when there is a twist in the tissue overlying the vascu- sence likely indicates an alternate diagnosis such as
lature (anteriorly) between the epididymis and the par- epididymo-orchitis [19]. A history of trauma should not
ietal tunica vaginalis [15]. discount the possibility of TT. Although the large
majority of cases of TT are unprovoked, 4–10% of pathognomonic of another cause, may be used to help
cases have been reported to occur in the setting of trauma place TT as a less likely diagnosis of the acute scrotum.
[5,9,20].
Laboratory investigations
Physical findings A urinalysis should be carried out as part of the routine
In a normal scrotum, the testis is mobile, and the cord and work-up. A positive dipstick result is more likely to be in
epididymis are palpable posterior to the testis. In TT, the keeping with epididymitis, especially in the setting of
affected testis is usually riding high. The globe of the dysuria and other features of a urinary tract infection.
testis is very tender, and venous distension and transu- However, a positive result does not exclude torsion,
date often result in a larger testis compared with the which can occur in rare instances [1].
contralateral and unaffected testis. Focal areas of ten- Routine blood tests may not need to be performed if the
derness in the superior testis or caput epididymis may clinical diagnosis is highly suspicious of TT, but may be
indicate a torted testicular appendix or epididymitis. useful in identifying other causes of the acute scrotum.
However, anatomical landmarks may be obliterated as An elevated C-reactive protein and white cell count for
oedema and erythema increase in later stages of torsion. example would be consistent with infection [5].
Assessment of the cremasteric reflex is important, and its
absence is generally considered one of the more reliable Role of imaging
physical signs of the presence of TT. The reflex is eli- High-resolution ultrasound (HRUS) with colour-flow
cited by stroking or pinching the medial thigh. Doppler ultrasonography (CDS) and radionuclide ima-
Contraction of the cremasteric muscle results in elevation ging can provide information on blood flow to the testes
of the testis, and the sign is considered positive if there is [25]. Absent arterial flow within the suspect testis on
movement of less than 0.5 cm on the affected side with a CDS is indicative of TT. However, the availability of
movement greater than 0.5 cm on the unaffected side. ultrasound in the emergency setting will vary between
One series of 245 boys presenting with acute scrotal institutions, and the results will be dependent on the skill
swelling reported absence of the cremasteric reflex in and experience of the radiographer or the radiologist.
100% of patients with torsion [21]. Similarly, in a large
Many studies advocate CDS as a useful tool in excluding
retrospective study of over 1200 cases over an 18-year
torsion and confirming other testicular pathology.
period, 94% of boys with TT had an absent cremasteric
However, the accuracy of CDS in diagnosing TT can
reflex [18]. Although the sign can be observer dependent
vary significantly in the literature. In a recent retro-
and published reports have shown an intact cremasteric
spective study of 298 patients who underwent CDS,
reflex in cases of TT, its absence should raise a sig-
followed by surgery regardless of the result, CDS was
nificant clinical suspicion of the diagnosis [5,22,23].
shown to have a sensitivity and specificity for TT of 96.8
The epididymis may be located medially, laterally or and 97.9%, respectively [5]. Positive and negative pre-
anteriorly, depending on the degree of torsion, but may dictive values were 92.1 and 99.1%, respectively. Other
appear normally located if there is 360° torsion, or may be studies have also shown similarly high sensitivity
difficult to palpate in a significantly oedematous scrotum. (95.7–100%) and specificity (85.3–100%) for CDS in
A reactive hydrocoele may be present, as well as scrotal diagnosing TT [26–28]. However, CDS can be inaccurate
oedema. and false negatives can occur, especially in cases of early
TT, intermittent torsion or incomplete torsion of the
A well-performed clinical examination may not reliably
spermatic cord. Several studies have reported arterial
exclude TT as a differential diagnosis and avoid scrotal
flow in affected testes, which were subsequently shown
exploration, but should raise significant concern where
to be torted at surgery [29,30]. Thus, delaying or avoiding
TT is likely and expedite management. Several studies
surgery in a patient with torsion and a false-negative
have shown that the most reliable physical signs of TT
ultrasonography can result in a missed diagnosis of TT;
include (a) a high-riding testis, (b) absent cremasteric
hence, many treating clinicians prioritize a strong clinical
reflex and (c) an anteriorly rotated epididymis or abnor-
suspicion over radiological findings in the decision of
mally oriented testis [18,19,24].
whether or not to perform scrotal exploration.
A febrile patient or erythema of the scrotum with or
HRUS can be used to directly visualize the spermatic
without a small hydrocoele may suggest an infective
cord along its entire length (beginning at the inguinal
process. However, the treating physician should be aware
canal to the posterosuperior border of testis) and assess
that these signs may be superimposed on an already
for any degree of twisting. In a retrospective study of 44
infarcted and necrotic testis.
patients with surgically confirmed TT, CDS detected
In children, other clinical indicators such as easily absent blood flow in only 31 patients (70% sensitivity),
jumping in and out of the bed, a normal appearance but HRUS detected twisting of the spermatic cord in all
lacking distress and a healthy appetite, although not 44 cases [31]. The authors described the appearance as a
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