Testicular Torsion

SUMMARY: Torsion of the testis is a surgical emergency that can occur at any age. Even though only one testis is affected, infertility and hormone deficiency are common consequences of delay in treatment . If there is any diagnostic uncertainty with or without diagnostic imaging, urgent surgery is the rule.

Clinical Features

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" testis^{2

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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.

Practice Point

Clinically atypical cases are common and clinical diagnosis alone is not reliable

Serious Consequences

Even though only one testis is affected, infertility and hormone deficiency are common consequences of delay in treatment.

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.

Practice Point

The potential Quantum of Damages is moderately high.

Urgent Surgery

If there is any diagnostic uncertainty with or without diagnostic imaging, urgent surgery is the rule.

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.

Practice Point

Surgery is required within 6 hours of onset of symptoms.