29.2 Torsion of Testes	605

Figs. 29.5 and 29.6 Clinical photographs showing two newborns with torsion of testis. Note the enlarged scrotum in both. Sometimes the skin is discolored and the affected testis is elevated

–Absence of cremasteric reflex

–Abnormal transverse lie of affected testis

Extravaginal Torsion

•In neonates, prenatal extravaginal torsion presents as a hard, nontender testis that is fixed to the overlying scrotal skin which is discolored (Figs. 29.5 and 29.6).

•The affected testis is swollen.

•Unilateral absence of the testis with blindending vas and vessels is thought to be a manifestation of early in utero torsion. This is also supported by finding hemosiderin in the distal section of the spermatic cord (Fig. 29.7).

•Acute scrotal swelling and tenderness without fixation to the scrotal wall, may represent a postnatal torsion with some hope of subsequent testicular salvage with early surgical management.

•Prenatal torsion manifests as:

–A firm, hard, scrotal mass

–It does not transilluminate

–It occurs in an otherwise asymptomatic, healthy and of good weight male newborn

–The scrotal skin characteristically fixes to the necrotic gonad and the scrotum is enlarged

Fig. 29.7 A clinical intraoperative photograph showing a small atrophic testis with an intact vas suggestive of intrauterine torsion of testis

29.2.5 Effects of Torsion of Testes

•Torsion of the testes causes venous occlusion and engorgement as well as arterial ischemia and subsequent infarction of the testis. The extent of this depends on two factors:

– The degree of torsion (Fig. 29.8):

•Torsion occurs as the testis rotates between 90° and 180°, compromising blood flow to and from the testis.

•Incomplete or partial torsion occurs with lesser degrees of rotation.

606	29 Acute Scrotum

	Fig. 29.8 A clinical photograph showing a newborn with	Fig. 29.9 A Doppler ultrasound showing torsion of the
		right testis
	extravaginal torsion. Not the already necrotic testis

•Complete torsion usually occurs when the testis twists 360° or more. The degree of torsion may extend to 720°.

–The duration of torsion:

•The duration of torsion is the most important factor that influences the rates of both immediate salvage and late testicular atrophy.

•Testicular salvage is most likely if the duration of torsion is less than 6 h.

•If 24 h or more elapse, testicular necrosis develops in most patients.

•The cause of decreased fertility observed in patients with unilateral testicular torsion is not known and two factors were suggested as possible theories.

–An inherent bilateral testicular abnormalities

–An autoimmune mechanism affecting the contralateral testis. This hypothesis however was not supported.

29.2.6 Investigations

•Testicular torsion is a clinical diagnosis.

•If the history and physical examination strongly suggest testicular torsion, the patient should undergo emergency exploration without delay to perform investigations and imaging studies.

•When a low suspicion of testicular torsion exists, color Doppler ultrasonography can be used to demonstrate arterial blood flow to the testis and provide information about other testicular pathology (Fig. 29.9).

•The sensitivity of color Doppler examination in detecting acute testicular torsion in children is 90–100 %, with specificity being 100 % (Figs. 29.10 and 29.11).

•Other studies have suggested that color Doppler ultrasonography was only 86 % sensitive, 100 % specific, and 97 % accurate in the diagnosis of testicular torsion.

•If the diagnosis is equivocal, radionuclide scan of the testis can be helpful to assess blood flow and to differentiate testicular torsion from other causes of acute scrotum.

•Radionuclide scans have a sensitivity of 90–100 % in detecting testicular blood flow.

•If the patient does not show clinical evidence of testicular torsion, a urinalysis and culture may help exclude urinary tract infection and epididymitis.

•The complete blood count can be normal. However, the WBC count is elevated in as many as 60 % of patients who have testicular torsion.

29.2.7 Treatment

•Surgical exploration and testicular detorsion is the definitive treatment for testicular torsion.

•Manual nonsurgical detorsion of the affected testis may be attempted but is usually difficult because of acute testicular pain during manipulation. During this maneuver, the testis should be detorted in medial to lateral direction.

29.2 Torsion of Testes	607

Figs. 29.10 and 29.11

A Doppler ultrasound showing epididymitis. Note the enlarged left epididymis and the good blood flow to the testis

•If manual detorsion is successful based on complete resolution of symptoms and confirmed by color Doppler ultrasound in a patient with testicular torsion, the patient should undergo definitive surgical fixation of both testes before leaving the hospital. The operation can be performed as an urgent rather than an emergency procedure.

•A bilateral scrotal orchidopexy is recommended to treat torsion of testis. This is to prevent torsion of the other testis.

•The treatment of neonatal torsion is still controversial.

–Some advocate elective rather than emergency exploration and contralateral orchidopexy because bilateral (synchronous or asynchronous) neonatal testicular torsion has been described.

–If the testis is necrotic, an orchiectomy and contralateral orchidopexy is performed.

–Retention of a necrotic testis may exacerbate the potential for subfertility, presumably because of development of an autoimmune phenomenon. This however is not fully supported.

–There are others who advocate emergency exploration.

•The argument in favor of this is that the timing of testicular torsion is not exactly known and although the chance of saving the testis is small, this is worth doing.

•Add to this the fact that these patients are usually healthy with no other abnormalities and of good size and currently the anesthesia is safe (Figs. 29.12, 29.13, 29.14 and 29.15).

•The placement of a testicular prosthesis is usually delayed for 6 months, until healing is complete and inflammatory changes resolve.