Testicular salvage and age-related delay in the presentation of testicular torsion

Testicular torsion represents a continuing source of morbidity among male patients. Early diagnosis and surgical exploration improve testis salvage but even this approach will result in orchiectomy if there is excessive delay in patient presentation. A 10-year retrospective review of testicular torsion was performed. The interval between onset of scrotal pain and presentation to the emergency department was determined. A specific age-related delay in presentation was identified between patients less than 18 years old (group 1, median delay 20 hours) and those greater than 18 years old (group 2, median delay 4 hours, p less than 0.001). At exploration 44 per cent of the group 1 patients required orchiectomy versus 8 per cent in group 2. Patients less than 18 years old are a high risk group for testicular loss after torsion and represent more than 90 per cent of the orchiectomies performed. We believe that this group should be targeted for improved health education, emphasizing early evaluation of scrotal pain to improve testicular salvage.     

Testicular torsion: a review

Torsion of the testis, also referred to as torsion of the spermatic cord, is a subject of debate among physicians and surgeons. Testicular torsion is an acute vascular event causing the rotation of the vascular pedicle of the testis, thereby impeding the blood flow to the testis and the scrotal contents. It could be either within or outside the tunica vaginalis. Testicular torsion causes immediate circulatory changes and long-term sequelae such as testicular function and fertility. It is considered a surgical emergency, as a delay causes irreversible testicular damage. The diagnosis and treatment of testicular torsion are discussed in this review, which also illustrates an algorithm and a scoring system for the diagnosis and management of this condition based on current literature.     

Testicular torsion: Nigerian experience

The records of 80 patients at this institution diagnosed as having testicular torsion during a 5-year period were examined to establish the characteristics and peculiarities, if any, of the disease in Nigeria. There were 74 suitable cases. Similar symptoms and physical signs were identified in Nigeria as have occurred elsewhere. However, contrary to reports from Europe and America the majority (57 per cent) of the patients with testicular torsion in this study were 20 or more years old. Also, torsion occurred significantly more often (9 per cent) in men 30 or more years old than has been reported in other areas. Only 5 per cent of the patients were less than 10 years old. There is no ready explanation why testicular torsion becomes manifest during adulthood in Nigeria. The testes were explored in 73 cases. Of the testes 25 per cent could not be salvaged because of infarction with acute torsion. However, the immediate testicular salvage rate of 75 per cent does not necessarily ensure long-term normal exocrine and endocrine testicular function.     

Testicular torsion after orchiopexy

We report 2 cases of testicular torsion after orchiopexy, which is rare but potentially catastrophic. A review of the literature revealed that absorbable suture was used in 15 of 16 cases of recurrent torsion. We conclude that the tunica albuginea should be secured to the scrotal wall with several nonabsorbable sutures to pex the testes permanently.     

Testicular function after torsion

A group of 20 patients with torsion was investigated. The study indicated that immediate surgical intervention with a period of torsion of the testis of less than 6 h will prevent impairment of testicle function. The histology of testicular biopsies taken from such patients revealed only interstitial oedema and, at the most, partial necrosis. If torsion time exceeded 6 h testicular histology revealed severe alterations, and surgical correction could not prevent atrophy of the testis. Patients with pathological spermiograms showed FSH values over or at the upper limit of the normal range. As far as can be concluded from one single basal hormone determination, the testosterone secretion remained unaltered. Libido, potency and virilization remained normal.     

Testicular torsion in children

The observations of 40 children with testicle torsion have shown results of the surgical treatment to depend not only on duration of the postoperative period but also on the degree of torsion and anatomical peculiarities of the spermatic cord. The preserved during operation testicle where non-recognized irreversible lesions have already occurred due to torsion can in later period result in the appearance of antisperm antibodies and threat of a lesion of the contralateral testicle.     

Testicular torsion: time is the enemy

BACKGROUND: The acute scrotum is a diagnostic dilemma, and testicular torsion is of primary interest because of its fertility problems for the patient and medico-legal issues for the surgeon. The present study aimed to correlate operative findings of patients with suspected testicular torsion with certain clinical variables and investigations to see if diagnosis and outcome could be improved. METHODS: A total of 99 patients underwent scrotal exploration for suspected testicular torsion at the Royal Brisbane Hospital between 1990 and 1995. Colour Doppler ultrasound, white blood count and urine microscopy results were documented, along with the patient's age and duration of testicular pain. RESULTS: Fifty-six patients were found to have torsion, and the testicular loss rate was 23%. Patients who experienced testicular pain for longer than 12 h had a testicular loss rate of 67%. A negative urine microscopy was suggestive of testicular torsion, but was not diagnostic. The white blood count did not aid in the diagnosis. Colour Doppler ultrasound of the scrotum was used on nine occasions with three false negative results and a sensitivity of only 57%. CONCLUSIONS: Time is the enemy when managing the acute scrotum. No investigation substantially improves clinical diagnosis enough to warrant any delay in definitive surgical intervention.     

Testicular torsion: Evaluation of contralateral testicular histology

Infertility may occur in patients with unilateral testicular torsion whose contralateral testis is intact. Depending on this observation, the physicians have begun to examine the contralateral testis. In the present prospective study we aimed to examine the histopathologic alterations occurring in the contralateral testicle with time. Sixty adult male albino rats were included in the programme, and following experimental torsion the histopathologic findings, especially those in the contralateral testis, were evaluated after 4–12 weeks. Long-term and high degree torsion of the testicle led to varying degrees of deterioration in the germinal epithelium and interstitial cells of the contralateral testicle. Histopathologic alterations were reversed in 12 weeks. Tubular diameter and testicular volume also decreased in accordance with the histopathologic alteration. In our opinion, orchiectomy following torsion of one testicle will limit potential histopathologic alterations in the contralateral testicle.     

Testicular salvage following spermatic cord torsion

There have been several reports indicating that men who have suffered from spermatic cord torsion are likely to have abnormal seminal analyses. It is now well recognized that unilateral spermatic cord torsion can result in contralateral testicular damage. This study was instituted to evaluate possible methods of preventing post-torsion contralateral testicular damage. Experimental torsion was produced in 250 g Wistar rats. The duration of torsion was either 3, 6, or 24 hours. The rats were then treated by one of three methods, namely, detorsion, immediate ipsilateral orchidectomy, or detorsion and adjuvant immunotherapy. Contralateral testicular damage was prevented by immediate ipsilateral orchidectomy and by detorsion with adjuvant immunotherapy. The immunotherapeutic agents administered were either hydrocortisone, azathioprine, or cyclosporin A. The results strongly support the premise that detorsion with adjuvant immunotherapy results in salvage of the ipsilateral testis while preventing contralateral testicular damage. Hydrocortisone is the immunotherapeutic agent of choice because its administration was associated with the fewest complications.     

Testicular torsion induced by epididymo-orchitis: A case report

Introduction and importanceAcute scrotum is considered a urological emergency requiring early intervention depending on the cause. There are multiple causes of acute scrotum with testicular torsion being the most feared as delayed treatment leads to testicular loss. However, differentiating between epididymo-orchitis and torsion can be very difficult.Case presentationWe present a case of an 18-year old male patient with 2 separate episodes of acute scrotum. He had epididymo-orchitis as the first presentation followed by testicular torsion 5 days later. To our knowledge this is the first case of testicular torsion secondary to epididymo-orchitis.Clinical discussionDifferentiating between epididymo-orchitis and torsion is challenging but important due to risk of loss of testis with a wrong diagnosis. Once you establish epididymo-orchitis the suspicion for subsequent torsion should be high with close follow up and adequate counselling.ConclusionHe ultimately had orchiectomy, although a rare presentation, enlarged testis due to epididymo-orchitis can predispose an individual to developing testicular torsion thus adequate counselling on warning signs to patients with epididymo-orchitis is of particular importance so as to intervene early and ultimately save the testis.     

Testicular torsion: Usefulness of contrast-enhanced power Doppler sonography

A 13-year-old-boy with suspected left testicular torsion was referred to our institute. During preparation, a significant decrease of signals on the left testis was found, however, slight blood flow was detected by the ultrasound examination enhanced by Levovist. As a result of the examination we left the testis intact, although the color of the testicular parenchyma remained black. One year after the surgery, an ultrasound examination was done again and good vascurality was observed.     

Testicular torsion: Management with ultrasonic doppler flow detector

The use of the ultrasonic Doppler flow detector in the management of acute testicular torsion is described. The Doppler can be used to diagnose torsion accurately and also to monitor manual detorsion. In this series detorsion was a reliable procedure which avoided emergency exploration in 5 of 8 patients with acute torsion. The advantages and limitations of the Doppler flow detector are presented.     

Testicular torsion in Bristol: a 25-year review

To identify changes in incidence, presentation, management and outcome, 670 patients with torsion of the spermatic cord presenting in Bristol between 1960 and 1984 have been reviewed. Among the susceptible population of 150,000, the annual incidence of torsion has increased fourfold from 11.2 cases between 1960 and 1964 to 42.8 cases between 1980 and 1984. Throughout this period greater than 90 per cent of patients have been managed by general surgeons. Patients aged between 12-18 years comprised 62 per cent but 20 per cent were 21 years or older. Torsion was commoner in the cold months, 24 per cent of cases occurring during December and January (chi 2 = 30.26, P less than 0.01). When acute torsion was relieved within 12 h of the onset of symptoms only 4 per cent of affected testes were considered non-viable, but beyond this time 75 per cent of patients received orchidectomy. Overall, 238 of 624 (38 per cent) acutely twisted testes were found to be infarcted at operation, and a further 35 patients (6 per cent) had marked testicular atrophy on review 3 months later. The testicular salvage rate has steadily improved from 45 per cent in the years 1960-64 to 67 per cent in 1980-84. Much of the increased incidence of testicular torsion is likely to reflect a greater awareness of the condition by general practitioners. It has been more than matched by an improvement in testicular salvage rate because of earlier referral.