Practice Easily Missed?

Testicular torsion

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c3213 (Published 27 July 2010) Cite this as: BMJ 2010;341:c3213
  1. Bhaskar K Somani, specialist registrar in urology1,
  2. Graham Watson, general practitioner2,
  3. Nick Townell, consultant urological surgeon1
  1. 1Ninewells Hospital, Dundee DD1 9SY
  2. 2Dundee
  1. Correspondence to: N Townell nicktownell{at}nhs.net
  • Accepted 18 May 2010

Case scenario

A 17 year old man presented with a 24 hour history of intermittent testicular pain without any urinary symptoms. The testis was mildly tender with no swelling and felt normal in size, shape, and position. A diagnosis of possible orchitis was made, but he was referred for further assessment. Surgical exploration found an engorged testis, confirming a diagnosis of intermittent torsion.

Testicular torsion is a surgical emergency requiring prompt diagnosis and specialist referral. In all cases of suspected testicular torsion, emergency surgical exploration is necessary to avoid loss of the testicle.

How common is it?

Testicular torsion has a bimodal age distribution, occurring either soon after birth or more commonly at puberty, but it can occur in any age group. The annual incidence in males <25 years is 1 in 4000.1 The incidence of testicular torsion, torsion of testicular appendage, and epididymitis was 16%, 46%, and 35%, respectively, in 238 children presenting with acute scrotal pain.2 In a prospective audit of 173 scrotal explorations for suspected testicular torsion over an 11 year period (1998-2008) in our centre, 89 (51%) had testicular torsion and 16 (9%) required an orchidectomy due to delayed presentation, with 75% (12) presenting 24 hours or more after onset of symptoms.3 When general practitioners were aware of possible testicular torsion and thus referred patients as soon as possible, the orchidectomy rate was lower than in patients who presented later and whose referral was delayed.4 5

Why is it missed?

Testicular pain and tenderness may be absent in up to a third of the patients.6 Swelling of the testis or scrotum, oedema or erythema of scrotal skin, and abdominal pain may be the presenting symptom in these cases. Pain may be intermittent (with episodes of torsion and detorsion) or a dull ache of gradual onset; it may also be referred to abdominal or inguinoscrotal regions. In a screaming male infant, the scrotum may not always be carefully examined to exclude a torsion, as this diagnosis may be overlooked as a cause for infant distress.

Why does this matter?

Torsion may lead to testicular ischaemia, with eventual haemorrhagic infarction and testicular necrosis.7 Ischaemic changes can begin within hours, and complete testicular atrophy will ensue in most cases after 24 hours8 unless surgical exploration results in manual detorsion. Detorsion within six hours of onset of symptoms has a salvage rate of 90-100%, which drops to 20-50% after 12 hours and to 10% after 24 hours.9 Normal sperm counts occur in only 5-50% of patients after orchidectomy or if testicular atrophy develops.10

How is it diagnosed?

Clinical features

Several case series describe the clinical features associated with testicular torsion, but exact prevalence is difficult to ascertain.6 11 12 Testicular pain occurs in 70-90% of cases, testicular or scrotal oedema in 60-75% of cases, abdominal pain in 7-28% of cases, and nausea or vomiting in 5-43% of cases.

Characteristically, testicular pain is of sudden and severe onset; it may radiate to the groin or lower abdomen and be accompanied by nausea, vomiting, and fever. Excluding a history of any other lower urinary tract symptoms such as frequency, urgency, or dysuria and taking a relevant social and sexual history can help exclude genitourinary infection as a cause of the symptoms.

Physical examination should include genital, inguinal, and abdominal examinations. Testicular examination should be done for lie (high or low) and axis (horizontal or vertical), comparing the affected to the unaffected side. Tender, elevated, transversely located testis with loss of cremasteric reflex suggests testicular torsion.12

Investigations

Urinalysis positive for nitrite and leucocyte esterase may indicate a urinary tract infection, although if a clinical suspicion of testicular torsion persists, the patient should be referred for specialist assessment. Colour duplex scrotal ultrasound may be useful. Absence of intratesticular blood flow was 86% sensitive, 100% specific, and 97% accurate in the diagnosis in one study,13 although accuracy rates are operator dependent, and peripheral flow may be present in early torsion or with episodes of torsion and detorsion. Hence, the decision to surgically explore should be made on clinical grounds. In our case scenario, intermittent testicular torsion was diagnosed from clinical history. Surgery in such cases results in resolution of pain and prevents future testicular infarction.14

How is it managed?

All clinically obvious cases of testicular torsion, or those diagnosed with colour duplex ultrasonography, should be treated as an emergency.15 Scrotal exploration with detorsion of the affected side and bilateral testicular fixation should be performed.16 Ideally a three point fixation of the testis within the scrotum prevents further torsion. Patients should also be warned about an orchidectomy if the testis cannot be salvaged.

Key points

  • Testicular torsion may be difficult to diagnose if symptoms are intermittent or atypical, but it must be considered in all cases of scrotal pain, with careful history and examination

  • Sudden, severe onset of testicular pain with tenderness should be considered as torsion and referred, unless other clinical features suggest an alternative diagnosis

  • Examine the testis for tenderness, size, shape, and position, and examine the remaining scrotal contents, comparing findings with the unaffected side

  • A colour duplex ultrasound scan may be very accurate if intratesticular blood flow is absent, but findings may not be diagnostic in early or intermittent torsion

  • Urgent scrotal exploration and bilateral testicular fixation should be performed in all cases of suspected testicular torsion

Notes

Cite this as: BMJ 2010;341:c3213

Footnotes

  • This is a series of occasional articles highlighting conditions that may be commoner than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, university lecturer in general practice, Department of Primary Health Care, University of Oxford, and Richard Lehman, general practitioner, Banbury. If you would like to suggest a topic for this series please email us (easilymissed.bmj{at}bmjgroup.com).

  • Contributors: BKS wrote the first draft of the article, which was modified by GW and NT. The final draft was agreed with NT. NT is the guarantor for the paper.

  • Funding: No external funding.

  • Competing interests: None declared.

  • Patient consent not required (patient anonymised, dead, or hypothetical).

  • Provenance and peer review: Commissioned; externally peer reviewed.

References