Summary

Testicular torsion is the twisting of the spermatic cord, which cuts off the venous drainage and subsequently the arterial supply to the testis. It is the most common urological emergency in adolescents. It requires Immediate Surgical Exploration. The viability of the testis is time-dependent: "Time is Testicle". [1,2]

Key Facts

• Golden Window: Salvage rate is ~100% at less than 6 hours. It drops to 50% at 12 hours and less than 10% at 24 hours.
• The "Acute Scrotum" Rule: Any acute scrotal pain in a young male is Torsion until proven otherwise.
• Bell-Clapper Deformity: The anatomical predisposition where the tunica vaginalis attaches high up on the cord (instead of the posterior testis), allowing the testis to swing freely and twist like a clapper in a bell. This is usually bilateral.

Clinical Pearls

The Absent Cremasteric Reflex: Stroking the inner thigh normally causes the testis to retract (L1/L2 reflex). In torsion, this reflex is almost always ABSENT. If the reflex is present, torsion is unlikely (but not impossible).

Abdominal Pain Trap: Embryologically, the testes descend from the abdomen. Therefore, testicular pain is poorly localised and often refers to the iliac fossa. Always examine the scrotum in any boy presenting with abdominal pain.

Imaging is the Enemy: If clinical suspicion is high, DO NOT order an Ultrasound. It causes a delay of 30-60 minutes which can mean the difference between salvage and orchidectomy. Ultrasound is only for equivocal cases.

• Cremasteric Reflex: Scrape inner thigh. Testis should rise.
• Prehn's Sign: Lifting the scrotum relieves pain?
  • Classic Teaching: Relief = Epididymitis. No Relief = Torsion.
  • Reality: Unreliable. Do not rely on Prehn's sign.
• Blue Dot Sign: A tender blue nodule at the upper pole suggests Torsion of the Hydatid of Morgagni (Appendix Testis). This is benign but can mimic torsion.

1. Testicular Infarction (Necrosis)

• Pathology: Haemorrhagic necrosis.
• Outcome: Loss of testis.
• Implication: Cosmetic (need for prosthesis later), Hormonal (other testis compensates usually), Psychological.

2. Sympathetic Orchidopathia

• Concept: Damage to the twisted testis breaks the "Blood-Testis Barrier".
• Mechanism: Sperm antigens (normally hidden) are exposed to the immune system. Anti-sperm antibodies are formed.
• Result: These antibodies attack the contralateral (healthy) testis.
• Risk: This is the main argument for performing Orchidectomy on a dead testis rather than leaving it in to atrophy.

3. Subfertility

• Even with salvage, the twisted testis often undergoes tubular atrophy.
• Sperm counts may be lower.
• However, paternity rates are usually preserved if the other testis is normal.

Salvage Rates

• 0-6 Hours: 90-100% Salvage.
• 6-12 Hours: 50% Salvage.
• 12-24 Hours: 20% Salvage.
• >24 Hours: <10% Salvage. (Usually dead).

Key Guidelines

1. EAU (European Association of Urology):
   • Colour Doppler US recommended only if low suspicion.
   • Manual Detorsion: Should be attempted if surgery delayed, but surgery still mandatory.
2. BAPU (British Association of Paediatric Urologists):
   • Consensus: The "Acute Scrotum" in a young male is a surgical emergency until proven otherwise.

(As per original - restored)

What is Torsion?

The testicle hangs on a cord (which carries blood vessels). If the testicle spins around, it twists the cord like a telephone wire, strangling the blood supply.

Why is it an emergency?

The testicle needs blood to survive. If the blood supply is cut off for more than 4-6 hours, the testicle dies. We have to untwist it before that happens.

Can you just check with a scan?

Scanning takes time. We don't have time. It is safer to look with a small operation than to wait for a scan and risk the testicle dying while we wait.

Why fix the other one?

The problem is caused by a loose attachment (Bell Clapper) that is usually present on both sides. If one twisted, the other one is very likely to twist in the future. We stitch it in place to prevent this ever happening again.

(As per original + Expanded)

Common Exam Questions

1. Diagnosis: "Most reliable sign?"
   • Answer: Absent Cremasteric Reflex.
2. Management: "First step in suspected torsion?"
   • Answer: NBM and Book Theatre (Not Ultrasound).
3. Anatomy: "Predisposing factor?"
   • Answer: Bell Clapper Deformity (High insertion of Tunica Vaginalis).
4. Surgery: "Procedure?"
   • Answer: Bilateral Orchidopexy (3-Point Fixation).

Viva Points

• Hydatid Torsion: How to tell? "Blue Dot Sign". Pain is less severe. Reflex is usually preserved. Management is conservative (analgesia), but if in doubt -> Explore.
• Appendicitis vs Torsion: In a boy with RIF pain? Always check scrotum. An inflamed appendix doesn't cause a swollen testis, but a twisted testis can cause RIF pain.
• Intermittent Torsion: History of severe pain that self-resolves. Exam normal. Still needs elective fixation because the next episode might not resolve.

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.