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Updated: Dec 22 2021

Testicular Torsion

  • Overview
  • Snapshot
    • A neonatal boy is brought to his pediatrician for concern of a blue mass in the scrotum. His parents noticed this an hour ago. On physical exam, the scrotum is blue and firm with some erythema. Transillumination test is negative. Doppler ultrasound shows absent blood flow. The neonate is immediately sent to hospital for surgery.
  • Introduction
    • Clinical definition
      • twisting of spermatic cord that results in compromised blood flow and ischemia
        • this is considered a surgical emergency
  • Epidemiology
    • Demographics
      • neonatal
      • adolescent years
    • Risk factors
      • prior history of testicular torsion
      • recent trauma to the testes
  • Etiology
    • Pathogenesis
      • processus vaginalis (path as testes leaves abdomen with peritoneal lining) twists, causing decreased or absent blood flow to the testis and epididymis
  • Presentation
    • Symptoms
      • primary symptoms
        • in adolescents
          • acute onset and severe pain in unilateral scrotum
          • nausea
          • vomiting
        • in neonates
          • blue and firm unilateral scrotal mass
    • Physical exam
      • inspection
        • high riding testis with a horizontal lie
        • erythema and swelling
      • tenderness to palpation
      • absent cremasteric reflex
  • Imaging
    • Doppler ultrasound
      • indications
        • if testicular torsion is suspected but not confirmed with physical exam and history
      • findings
        • decreased or absent blood flow
  • Studies
    • Urinalysis
      • to rule out epididymitis
    • Diagnostic criteria
      • diagnosed by history and physical exam
      • diagnosis confirmed only during surgery
  • Differential
    • Epididymitis
      • positive cremasteric reflex
    • Torsion of the appendix testis
      • normal cremasteric reflex
      • normal testicular lie
      • positive blue dot sign
  • Treatment
    • Operative
      • orchiopexy (bilateral)
        • indications
          • within 24 hours of disease onset
            • 4-8 hour window before there is permanent damage from ischemia
        • bilateral orchiopexy should be performed as contralateral testis is also at risk for future torsion
        • outcomes
          • 90-100% with viable testes if within 6 hours
          • 50% if within 12 hours
          • <10 % if after 24 hours
      • orchiectomy
        • indications
          • if testis is not viable
    • Non-operative
      • manual detorsion
        • indications
          • if surgery is not available or delayed
  • Complications
    • Testicular ischemia
    • Infertility or subfertility
  • Prognosis
    • Prognostic variable
      • favorable
        • rapid time to surgery
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