Rigi10™ Malleable Penile Prosthesis
Also Known As
Torsion of the testicle, Twisted testicle, Spermatic cord torsion
Definition
Testicular torsion is a critical medical emergency that occurs when a testicle rotates on its axis, twisting the spermatic cord. This cord is vital as it supplies blood to the scrotum, the loose pouch of skin beneath the penis that houses the testicles. The twisting of the spermatic cord obstructs blood flow to the affected testicle, leading to a rapid onset of severe pain and significant swelling in the scrotal area.1,2,3 The reduction or complete blockage of blood supply can cause irreversible damage to the testicular tissue if not treated promptly, potentially leading to the loss of the testicle.2,3
This condition primarily affects males, with the highest incidence observed in adolescents between the ages of 12 and 18 years, although it can manifest at any age, including in newborns and older men.1,3 The underlying cause is often related to an anatomical characteristic known as the “bell clapper” deformity, an inherited trait where the testicle is not securely attached to the scrotal wall, allowing it to move and rotate more freely within the tunica vaginalis.1,3 Testicular torsion can occur spontaneously, even during sleep, or it may be triggered by vigorous physical activity, minor trauma to the testicles, or even rapid growth spurts during puberty.3
The primary purpose of understanding and recognizing testicular torsion is to facilitate immediate medical intervention. Prompt diagnosis and surgical treatment are crucial to salvage the affected testicle and prevent long-term complications such as infertility or the need for orchiectomy (surgical removal of the testicle).1,3 Healthcare professionals and patients alike should be aware of the hallmark symptoms, which include sudden, intense scrotal pain, swelling, abdominal pain, nausea, vomiting, and a testicle that may appear higher than normal or at an unusual angle.3
Clinical Context
Testicular torsion is a urological emergency that necessitates immediate clinical attention to prevent irreversible testicular damage or loss.1,2,3,4 Clinically, it is characterized by the acute onset of severe, unilateral scrotal pain, which may also be accompanied by swelling of the scrotum, nausea, vomiting, and abdominal pain.1,3,4 The pain can sometimes radiate to the groin or lower abdomen. In some instances, particularly in younger boys, the pain might awaken them from sleep.3
The condition is most frequently encountered in adolescent males, typically between the ages of 12 and 18, but it is important to recognize that testicular torsion can occur at any age, including in neonates (newborns) and older adult men.1,3,4 Neonatal torsion often presents differently, sometimes as a firm, discolored, and non-tender scrotal mass, and unfortunately, the affected testicle is often non-viable by the time of diagnosis.4
Patient selection for immediate surgical intervention is primarily based on clinical suspicion, supported by the patient’s history and physical examination findings. Key physical findings that raise suspicion for testicular torsion include a high-riding testicle, an abnormal (transverse) lie of the testicle, absence of the cremasteric reflex on the affected side, and significant tenderness and swelling of the testicle and scrotum.1,3 The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score, which incorporates findings like testicular swelling, hard testis, absent cremasteric reflex, nausea/vomiting, and high-riding testis, can aid in risk stratification, with high scores strongly suggesting torsion and prompting surgical exploration often without further imaging.1
While clinical diagnosis is paramount, a color Doppler ultrasound is the primary imaging modality used to confirm the diagnosis when there is uncertainty. This imaging technique can assess blood flow to the testicle; diminished or absent blood flow is a hallmark sign of torsion.1,3 However, reliance on ultrasound should not unduly delay surgical intervention if clinical suspicion is high, as time is critical to testicular viability. The salvage rate for a torsed testicle is nearly 100% if surgical detorsion and orchiopexy (fixation of the testicle) are performed within 4 to 6 hours of symptom onset. This rate drops significantly to below 50% if treatment is delayed beyond 12 hours, and approaches 0-10% after 24 hours.1,3,4
The definitive treatment for testicular torsion is surgical. The procedure involves making an incision in the scrotum, manually untwisting the spermatic cord, and assessing the viability of the testicle. If the testicle is viable, it is then fixed to the scrotal wall (orchiopexy) to prevent future torsion. Because the anatomical predisposition (e.g., bell clapper deformity) is often bilateral, the contralateral (unaffected) testicle is also typically fixed prophylactically during the same surgery to prevent future torsion on that side as well.1,3,4 If the testicle is found to be non-viable due to prolonged ischemia, an orchiectomy (surgical removal of the affected testicle) is performed.1,3
Expected outcomes are highly dependent on the duration of torsion before surgical correction. Early intervention leads to excellent testicular salvage rates and preservation of function.1,3,4 Delays can result in testicular atrophy (shrinkage), loss of the testicle, and potential impacts on fertility, although having one healthy testicle is generally sufficient for normal fertility and testosterone production.4 Some studies suggest a possible link between testicular torsion and reduced sperm quality or the development of anti-sperm antibodies, but significant infertility is rare if the contralateral testis is normal.4 Post-operatively, patients usually recover well, with pain management and activity restrictions for a period. Follow-up with a urologist is important to monitor recovery and testicular health. For patients who undergo orchiectomy, a testicular prosthesis may be considered at a later stage for cosmetic reasons.4