Torsion of the testis usually occurs during childhood or adolescence, though adults and even middle-aged men are not immune1.
In the majority of cases there are abnormal anatomical attachments from before birth and the testis is unusually mobile, the so-called "bell clapper" testis2 .
Strictly speaking, it is the spermatic cord not the testis that twists, though the spermatic cord carries the blood-supply and the end result of torsion is destruction (infarction) of the testis.
In adolescence and beyond, the usual confusion is with epididymitis, (usually sexually-transmitted) inflammation of the sperm reservoir (epididymis). Symptoms and signs of typical testicular torsion and epididymitis are distinct3 but, as with most medical conditions, the majority of cases are not typical and there is considerable overlap in the clinical presentation4.
Young boys in particular may report or poorly localise the pain in the groin or even the lower abdomen, often out of embarrassment5. Sudden onset of pain at any age is very suggestive of torsion, but slower onset is not rare5.
Clinically atypical cases are common and clinical diagnosis alone is not reliable
Although torsion is not that common, misdiagnosis or operative delay often results in loss of the testis, hormone deficiency and infertility - and not infrequently an Action for medical malpractice6.
The anatomical abnormalities which predispose to testicular torsion are usually bilateral, and may result in other conditions such as undescended testis.
Even when an undescended testis is surgically corrected early, it may function poorly. The other more normal testis may have descended normally from the abdomen into the scrotum during fetal life or early childhood, be adequately functioning but remain susceptible to torsion.
The potential Quantum of Damages is moderately high.
Because the potential consequences of failure to operate urgently are so serious, the "acute scrotum" should be considered as testicular torsion until proved otherwise7, and surgically explored urgently if there is any doubt8.
The diagnostic imaging gold-standard is emergency ultrasound with colour doppler display4, but this investigation is not always available in community hospitals. Only if the imaged blood supply to the testis is demonstrably normal should an "acute scrotum" that is in any way atypical for an alternative diagnosis be spared surgical exploration.
The "window of opportunity" for salvage of the testis may be as little as 4-6 hours from onset of symptoms3.
Surgery is required within 6 hours of onset of symptoms.
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