Testicular Torsion Fani Final

8/14/2019 Testicular Torsion Fani Final

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TesticularTesticular

TorsionTorsion

Dr Malik Irfan AhmedDr Malik Irfan Ahmed

MO SUIIMO SUII


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Epidemiology/Risk FactorsEpidemiology/Risk Factors

1/4000 males


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Epidemiology/Risk Factors (cont)Epidemiology/Risk Factors (cont)

Other (2-6% of cases): Increase in testicular volume (puberty)

testicular tumor

testicles with horizontal lie spermatic cord with long intrascrotal portion

Cryptorchidism (one or both testes)

Strenuous exercise


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PathophysiologyPathophysiology

The testicle is typically covered bythe tunica vaginalis.

The tunica vaginalis attaches to theposterolateral surface of the testicleand allows for little mobility of thetesticle within the scrotum.


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Types Of testicular TorionsTypes Of testicular Torions

Two Types

Intravaginal

Extravaginal


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Intravaginal testicularIntravaginal testiculartorsiontorsion

In patients who have an inappropriatelyhigh attachment of the tunica vaginalis,the testicle can rotate freely on thespermatic cord within the tunica vaginalis.

This congenital anomaly, called the bellclapper deformity, results in the long axisof the testicle to become orientedtransversely rather than cephalocaudal.

Present in approximately 12% of males 40% of which have the abnormality in thecontralateral testicle as well.


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The bell clapper deformity allows the testicle totwist spontaneously on the spermatic cord,causing venous occlusion and engorgement,with subsequent arterial ischemia causing

infarction of the testicle. Experimental evidence indicates that 720

torsion is required to compromise flow throughthe testicular artery and result in ischemia.


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Bell Clapper DeformityBell Clapper Deformity


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Extravaginal testicularExtravaginal testiculartorsiontorsion

In the neonatal age group, the testiclefrequently has not yet descended into thescrotum, where it becomes attached within

the tunica vaginalis. This mobility of the testicle predisposes it to

torsion .

Inadequate fusion of the testicle to the

scrotal wall, moreover, typically occurswithin the first 7-10 days of life.


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Other Causes/PrecipitatingOther Causes/Precipitatingfactorsfactors

Sexual arousal and/or activity

Trauma Exercise

Active cremasteric reflex

Cold weather


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Diagnosis isDiagnosis isCRITICAL!!CRITICAL!!


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Initially obstructsInitially obstructsvenous returnvenous return

Equalization of venous and

arterial pressures

Compromised arterial flow

TESTICULAR ISCHEMIA

As soon as4 hours!!

Testicular TorsionTesticular Torsion


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ISCHEMIA vs Salvage RateISCHEMIA vs Salvage Rate

ISCHEMIA: as soon as 4 hrs almostCERTAIN in 24 hrs

Salvage Rate:

90-99% success if < 6 hrs

50% success if


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TesticularTesticular PAIN!PAIN!16-42% acute scrotal pain

TESTICULAR TORSION


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HistoryHistory

History includes a sudden onset of severe unilateral scrotalpain.

As many as 50% of patients have a history of priorepisodes of intermittent testicular pain that has resolvedspontaneously (intermittent torsion and detorsion).

Onset of pain can occur more slowly, but this is anuncommon presentation of torsion.

Torsion can occur with activity, be related to trauma, ordevelop during sleep and includes the following: Scrotal swelling Nausea and vomiting (20-30%)

Abdominal pain (20-30%) Fever (16%) Urinary frequency (4%)


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PhysicalPhysicalExaminationExamination

Involved testicle painful to palpation; frequentlyelevated in position when compared with theother side

Horizontal lie of the testicle

Enlargement and edema of the testicle; edemainvolving the entire scrotum Scrotal erythema Ipsilateral loss of the cremasteric reflex Prehn sign -Ve

Fever (uncommon) Epididymis: medially, laterally or anteriorly

(depends on degree of torsion) one side


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DifferentialDifferentialDiagnosisDiagnosis

Epididymitis/Orchitis

IncarceratedHernia

IdiopathicScrotal Edema

VaricoceleTorsion of

Appendix Testis


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Other Problems to beOther Problems to be

ConsideredConsidered

Traumatic rupture

Traumatic hematoma Torsion of testicular appendage


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Lab StudiesLab Studies Complete blood count:

CBC can be normal or show an elevated WBC count in asmany as 60% of patients who have torsion

Urinalysis Urinalysis result is usually normal. The presence of white blood cells (WBCs) can be observed in

as many as 30% of patients who have torsion

Acute-phase proteins (C-reactive protein [CRP]): Elevationin acute-phase proteins, namely the CRP, has beenpostulated as a diagnostic aid in differentiatinginflammatory causes of acute scrotal pain (epididymitis)

from noninflammatory causes (testicular torsion).


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Diagnostic ModalitiesDiagnostic Modalities

Doppler UltrasoundDoppler UltrasoundRadionuclide Testing

Surgical Exploration

Imaging:ONLY IF

SUSPICION FORTORSION =LOW

Faster More available Plain doppler has lessaccuracy than color one More sensitive

E l f l PE l i f A S l P i


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Evaluation of Acute Scrotal PainEvaluation of Acute Scrotal Pain


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Line of ManagementLine of Management Early diagnosis and prompt urologic referral is

essential since time is critical in salvage of thetesticle.

Mild analgesic pain relief can be administered

once testicular torsion has been diagnosed orwhile awaiting further studies.

Attempt manual detorsion, which can beattempted with pain relief as the guide forsuccessful detorsion. The procedure is similar to

the "opening of a book" when the physician isstanding at the patient's feet.


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book

Most torsions twist inward and toward the mid line; thus,manual detorsion of the testicle involves twisting outwardand laterally.

For example, in a suspected torsion of the right testicle, thephysician is in front of the standing or supine patient and holdsthe patient's right testicle with the left thumb and forefinger.

The physician then rotates the right testicle outward 180 in amedial to lateral direction.

Rotation of the testicle may need to be repeated 2-3 times forcomplete detorsion and to provide pain relief to the patient.

For the patient's left testicle, the physician uses the right thumband forefinger and rotates the patient's left testicle in anoutward direction 180 from medial to lateral.

Manual detorsion is successful in 30-70% of patients.

open


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Orchipexy is the Surgery of thechoice for testicular torsion

Should be performed on unaffectedside as well.


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Most Significant ComplicationMost Significant Complication Infarction of testicle

Loss of testicle

Infection

Infertility secondary to loss oftesticle

Cosmetic deformity


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Thank you


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Testicular Torsion Fani Final

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