Torsion of the testis

• *An emergency!
• Failure to detort testis within 6 hours leads to testicular necrosis.
• 2 types of testicular torsion
• *Extravaginal: occurs in the perinatal period/during infancy due to an
undescended testis.
• *Intravaginal: due to a high investment of tunica vaginalis causing a bilateral
“bell-clapper” deformity from 10 to 14 years old.
Clinical features
• Sudden severe pain in the scrotum and referred to the lower
abdomen
• Nausea and vomiting
• Fever or UTI (late symptoms)
Physical findings
• Early
• Involved testis – high, tender, swollen.
• Spermatic cord – swollen, shortened and tender.
• Contralateral testis – abnormal lie, usually transverse.
• Late
• Same findings as early presentation, however, reactive hydrocele and scrotal
oedema make it difficult to examine.
Investigations
• Laboratory tests are unlikely to be of consequence, as no single test
has high sensitivity or specificity in diagnosing testicular torsion.
*Unless there is strong suspicion of an alternative diagnosis*
• Colour Doppler Ultrasonography – 85% sensitivity, 100% specificity to
look for intratesticular arterial blood flow and spiral twisting of the
spermatic cord. *So if there’s minimal to no intratesticular arterial
blood flow and there is spiral twisting of the spermatic cord, the
patient is said to have testicular torsion. Even so imaging studies
usually are usually not necessary as ordering them wastes valuable
time when the definitive treatment is emergent urologic consultation
for surgical management.*
Diagnosis
• *TWIST (Testicular Workup for Ischemia and Suspected Torsion)
scoring system – determine the risk of testicular torsion on clinical
grounds; decreasing the indication for ultrasound.
• TWIST consists of the following urological history and physical
examination parameters:
• Testis swelling (2 points)
• Hard testis (2)
• Absent cremasteric reflex (1)
• Nausea/vomiting (1)
• High-riding testis (1)
Diagnosis
• TWIST scores and risk groups are as follows:
• 0-2 points - Low risk
• 3-4 points - Intermediate risk
• 5-7 points - High risk
• Ultrasound evaluation is indicated for intermediate-risk patients; low-
risk patients do not require ultrasound to rule out torsion, and
patients at high risk can proceed directly to surgery.
Torsion of testicular appendages
• Torsion of the testicular appendages is a twisting of a vestigial
appendage that is located along the testicle.
• The appendages are Mullerian and mesonephric duct remnants and
has no function, yet more than half of all boys are born with one.
• Importance: in a late presentation, may be confused with torsion of
testis.
Clinical features
• Age of onset: 8 to 10 years old.
• Sudden onset of pain, mild initially but gradually increases in intensity.
Physical findings
• Early
• Minimal redness of scrotum with a normal non-tender testis.
• Tender nodule “blue spot” (upper pole of testis) is pathognomonic.
• Late
• Reactive hydrocele with scrotal oedema makes palpation of testis difficult.
Epididymo-orchitis
• Can occur at any age
• Route of infection includes the following:
• Reflux of infected urine
• Blood borne secondary to other sites
• Mumps
• Sexually transmitted infection
Clinical features
• Gradual onset of pain with fever.
• May have a history of mumps.
• ± Dysuria/ frequency.
Physical findings
• Testis may be normal with a reactive hydrocoele.
• Epididymal structures are tender and swollen.
Investigations
• Urinalysis and urine culture *to identify causal organism which is
usually bacterial in origin, the most common pathogen being
Neisseria gonorrhoeae in men aged 14-35 years, and Escherichia coli
in boys younger than 14 years and in men older than 35 years.*
• Investigate for underlying structural anomalies of the urinary tract
and voiding dysfunction
• Rule out sexual abuse