testicular torsion

Testicular Twist: Description

The testicular torsion (also testicular rotation or testicular twisting) around the longitudinal axis of the vas deferens and vascular cord is a dangerous complication, because it can block the blood supply of the testicle completely or completely.

If only the vein (testicular vein) and therefore the venous outflow are pinched off by the testicle rotation, while the artery (arteria testicularis) continues to pump blood to the testicle due to the higher blood pressure prevailing therein, there is an incomplete torsion. The blood accumulates in the testes, which then secondary to the arterial inflow can be affected. As a result, it can lead to the death of testicular tissue (hemorrhagic testicular necrosis).

If testicular torsion interrupts both venous outflow and arterial supply of blood, it is called a complete torsion. Again, it comes quickly to the death of tissue.

If both testicles are twisted at the same time, this is called bilateral testicular torsion.

A testicular torsion is possible in principle at any age, but occurs especially in the first year of life and between the 12th and 18th year. With increasing age a testicular torsion occurs less and less often.

There are two main forms of testicular torsion: extravaginal and intravaginal testicular torsion.

Extravaginal testicular torsion

This variant is the most common. It occurs especially in infants and toddlers before the second year of life: The spermatic cord then twists above the testicle envelope, a connective tissue pouch in which the testes rests in the scrotum.

Intravaginal testicular torsion

This form of testicular rotation, which is more common in adolescents, occurs within the testicular sheath and thus closer to the testicle itself. Here, too, the blood supply is disturbed or interrupted by the twisting of the spermatic cord.

Hydatid torsion

No real testicular torsion is the so-called Hydatidentorsion, in which the testes attached residual structures from the embryonic time twist. The symptoms are similar to those of testicular torsion, but are often less severe. Damage to the testicular tissue itself does not occur at first, however, can be affected by the dead testicular appendages testicular tissue and cause blood poisoning.

Testicular torsion: symptoms

The main symptom of testicular torsion is a sudden pain in the affected side of the scrotum. With pressure or often already with mere contact the pain usually increases significantly, besides, it can radiate at the appropriate half of the body into the inguinal canal and / or lower abdomen.

Sometimes the typical symptoms are accompanied by vegetative complaints. These include nausea and vomiting, sweating and an accelerated heart rate to the point of shock. Without treatment of testicular torsion, the testicles swell and the skin of the scrotum reddens.

In about one-third of patients with testicular torsion, there are first recurrent incomplete torsions, with only fleeting symptoms appear, which disappear again because the affected testicular sponate turns back. It does not seem to cause permanent damage, but it increases the risk of treatment-induced testicular torsion.

A special case is the twisting of the testicles in infants, because they may be crying over pain, but they can not show the place of pain. Diffuse abdominal pain, navel colic, motor restlessness, vomiting and refusal to eat may indicate testicular torsion.

A testicular torsion can also occur in a non-descended (not descended) testicles: The testicles arise in the abdomen and usually descend into the scrotum until birth. Sometimes this descent remains – one or both testicles remain in the abdomen (abdominal testes) or migrate only to the inguinal canal (inguinal testes). It is difficult to diagnose a torsion in an undescended testicle. The twisting of a right-sided abdominal testicle is often confused with acute appendicitis due to diffuse symptoms. The torsion of a groin leads to a painful swelling in the groin area with redness and overheating.

Testicular torsion: causes

The prerequisite for testicular torsion is usually a hypersensitivity of the testes within its sheaths and its suspension due to anatomical abnormalities. Then often enough small triggers to bring about a testicular torsion.

Anatomical risk factors for testicular torsion

The risk factor for testicular torsion, for example, is the incorrect attachment of the testicular sheaths, for example if they do not adhere sufficiently in the course of development. This gives the flat-oval testicles too much room to move. The result is usually an intravaginal testicular torsion.

In addition, a testicular torsion is favored when the so-called lower gonadal ligament is insufficient or not formed. This structure, called Gabernaculum testis, is used to pull testicles down into the scrotum after birth (testicular descent or descensus testis). Thereafter, it forms into two bands that hold the testicles in place. An incomplete testicular descent (also undescended testis or maldecensus testis) is a risk factor for testicular torsion.

Together with the vas deferens and the vessels runs a slender muscle (cremaster muscle), which pulls the testicles for temperature regulation, to protect against injury or in case of great sexual excitement to the body. If its insertion on the testicle is unfavorable, its reflex-like contraction may favor a testicular twisting.

Finally, previous operations on the scrotum or testicles can also encourage testicular torsion. For example, the non-optimal return displacement of the testicle during so-called water rupture may increase the risk of testicular rotation.

Direct trigger for testicular torsion

If the anatomical risk factors are very pronounced, testicular torsion can occur very quickly – even when moving during sleep.

In addition, any physical activity can cause testicular torsion as the testicles move. Therefore, the injury often occurs during sports or games. Cycling is considered a particular risk factor, because here the testicles constantly “roll” over the nose of the bicycle saddle.

Testicular torsion: examinations and diagnosis

If you suspect a testicular torsion, the doctor should examine the patient immediately. Relevant background information such as onset and intensity of symptoms, known undescended testicles, through or accompanying infections (especially viral infections) can ask the doctor of the parents or in elderly patients of these themselves.

Physical examination

The doctor examines the affected testicles and pays attention to, for example, swelling, redness, asymmetry (compared to a healthy testicle) and bruising. The inguinal region and the abdomen (abdomen) are also examined in order to identify any diseases that radiate with their symptoms to the testes.

Special examinations may confirm or disprove the suspicion of testicular torsion:

If the pain remains unchanged or even increases when the affected testicle is raised (negative Prehn sign), this indicates a testicular torsion. This test is mainly used to exclude testicular / epididymitis (orchitis / epididymitis), in which by lifting the scrotum, the pain subsides (Prehn sign positive).

The doctor can also test the cremaster reflex: when he strokes the inside of the thigh, the cremaster muscle usually contracts reflexively, pulling the testicle up the side of it. This is not the case with testicular torsion. However, it should be noted that the Kremaster reflex is less pronounced in infants and adolescents than in adults.

By standing up the twisted testicle, the skin of the scrotum is pulled inwards. This is called the “Ger sign”.

The “Tenkhoff sign” is a kind of crackle when touching the scrotum. It also indicates a testicular twist.

laboratory examination

To exclude inflammation (such as testicular, epididymal, urinary tract infection) as the cause of the complaints, laboratory tests are useful. In the blood important inflammatory parameters such as the C-reactive protein, the leukocytes and the erythrocyte sedimentation rate are measured. The urine can be examined for bacteria and sediments.

Imaging diagnostics

The most reliable examination for suspected testicular torsion is sonography (ultrasound). It allows an assessment of the nature of the testicular tissue and may represent swelling and jammed blood vessels. A supplement to the study is the Doppler sonography, which can represent the blood flow in the testicular vessels. However, both examinations require a great deal of experience and should be performed by a urological specialist.

Even with a scintigraphy one can detect a testicular torsion. This special form of X-ray examination measures whether and how quickly a radioactive contrast agent is distributed in the testicular tissue. In a testicular torsion, this process is delayed or does not take place at all. However, this method is not routinely used to clarify a testicular torsion because of the radiation exposure.

Also by means of magnetic resonance tomography (MRI), diseases of the testicle such as a testicle rotation can be displayed very reliably. Because the examination is very time consuming, not everywhere possible and very expensive, it is not a routine test for testicular torsion.

If the results of an instrument diagnostic are not clear, but the symptoms indicate a testicular rotation, appropriate treatment should be initiated.

Testicular torsion: treatment

Top priority in the treatment of testicular torsion is speed! The more time passes before the blood supply can be restored, the more likely is the loss of the testicle. In textbooks and studies, this time is estimated at six to eight hours, a testicular receiving intervention should therefore take place as early as possible.

The open therapy of testicular torsion

Testicular torsion is almost always treated surgically – preferably within the first four to six hours. The doctor opens the scrotum directly or via the inguinal canal. If the testicle is free, it must determine the direction of the testicular torsion and turn the testicle accordingly back to its original position.

To determine if the testicle is recovering, wait for up to 30 minutes to check if the blood flow in the blood vessels gets going again. If not, testicular tissue is already dead and the necrotic testis must be removed.

If it is not clear to what extent the testicle has already been damaged, it is usually left in the scrotum. It is believed that even with partial destruction of the testicular tissue, there is still some residual function that can contribute to the production of hormones and sperm.

Now, the testes are fixed down in the scrotum to reduce the risk of re-twisting. This is called orchidopexy. This attachment is necessary because the risk of another testicular torsion would otherwise be particularly large. An orchidopexy does not completely rule out a new twist, however.

Since the probability of a testicular rotation is higher on the opposite side, the testes are also sutured to the scrotum, usually within the same operating room. However, this procedure is postponed if the twisted testicle was already severely damaged so as not to hinder the healing process.

After the operation, the testicles should be cooled for pain relief and stored on a so-called testicle bench. These are very soft pads, which are pushed while lying under the scrotum.

The non-operative therapy of testicular torsion

Testicular torsion can sometimes be treated without surgery. An experienced examiner then tries to turn the testicles back through the skin through external grips. If the pain eases promptly and everything looks normal again when you are palpating, this speaks for the success of the treatment. In any case, within 12 to 24 hours, both testicles should be sutured to the scrotum (orchidopexy) to avoid further testicular torsions.

Due to the great uncertainty of the procedure, manual therapy is not used as an alternative to surgical treatment, but as an initial treatment in emergency situations, if a timely operation is not possible for certain reasons.

Testicular torsion: Disease course and prognosis

If testicular torsion is treated within the first hours of onset of symptoms, the testicle usually recovers completely. However, the longer the blood supply was interrupted, the lower the chances of maintaining functional testicular tissue.

Prolonged testicular torsion can also endanger the testicles of the other side, because certain vascular reflexes and messenger substances can also affect its blood supply. Even so-called autoantibodies, which are actually directed against dead testicular tissue, can attack the healthy testicles (contralateral testicular damage).

In 36 to 39 percent of patients with testicular torsion, fertility is limited.

After a testicle rotation, bilateral orchidopexy should always be performed. The attachment to the scrotal tissue may increase the risk of recurrence testicular torsion significantly lower.