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Updated 27 March 2013

Testicular torsion - why it is so painful

Testicular torsion is a condition in which the testis becomes twisted upon itself within the scrotum. This cuts off the blood supply to the testis.

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Description and comments

Testicular torsion is a condition in which the testis becomes twisted upon itself within the scrotum. This cuts off the blood supply to the testis.

It is the most common cause of scrotal pain, accounting for up to 42% of cases. Torsion can occur at any age, though it is most often seen in newborns and in young boys post-puberty.

Symptoms and signs

Torsion (twisting) of the testis within the scrotum causes very sudden, severe scrotal pain, often with associated nausea and vomiting. This may even occur during sleep, with the pain wakening the patient.

On examination, one testis will be higher up than the other, and may seem more horizontal than vertical within the scrotum. Swelling may be gross, with overlying redness, and the testis is extremely tender and sensitive. The cremasteric reflex (contraction of the scrotum when touched) is usually absent.

Differential diagnosis

Other conditions which may be confused with testicular torsion are:

  • torsion of the appendix testis
  • epididymitis
  • inguinal hernia
  • mumps orchitis
  • post-vasectomy problems
  • Fournier's gangrene(necrotising fasciitis of the scrotum)
  • referred pain from other disorders such as
    • abdominal aortic aneurysm
    • kidney stones
    • lumbar or sacral nerve entrapment
    • retroperotineal tumours

Causes

Testicular torsion is possible if the testis is not properly secured to the inside of the scrotum: during normal development of the foetus, the testes descend into the scrotum, and are held there by specific tissues. If this does not happen correctly, the testes may be able to rotate inside the scrotal sac, and become twisted.

The twisting shuts off the blood supply to and from the testis, leaving it congested and without oxygenated blood. The testis has no alternative route of blood supply to use to keep it alive if it undergoes torsion. No organ in the body can survive indefinitely without an adequate blood supply.

Diagnosis

The diagnosis is mainly clinical, but can be confirmed by ultrasound if time permits, or if the diagnosis is in doubt.

Treatment

Treatment consists of "untwisting" the testis as soon as possible - the longer it remains twisted, the higher the chances of complications , the most important of which are death of the testis and gangrene.

If immediate surgery is not possible, an attempt to manually de-rotate the testis is reasonable. In most cases, gently rotating the testis away from the midline gives immediate relief of pain. If pain increases, then the testis must be rotated the other way.

Even if manual de-rotation succeeds, surgery is still needed as soon as possible to assess viability of the testis, and to fix it in the correct position, to prevent recurrences. Both testes must be fixed in position during the surgery. If the torsion was left too long before surgery, the testis may no longer be viable, and will have to be removed.

Complications

The complications of untreated torsion are

  • necrosis(death) of the testis
  • possible gangrene
  • infection
  • decreased fertility

The surgery for torsion is seldom complicated. Problems associated with surgery in general are

  • anaesthetic problems
  • bleeding
  • infection

Outcome

Provided the testis is untwisted within 4 -5 hours of the onset of symptoms, it remains viable with no decrease in function. Longer delays decrease viability, and no testis can survive 24 hours of torsion.

 
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