Torsion testis - CASE STUDY

Hi guys.....posting after a really long time....
This is my first case of torsion testis.

Torsion testis

Findings :

Left testis was enlarged in size and heterogenous in apperance and most importantly NOT taking any vascularity. Right testis is there for comparison at the same blood flow settings.

Left cord was inflamed and hyperechoic in appearance and the vessels showed a 'whirlpool' appearance.

DISCUSSION

Introduction

Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood supply. The most common symptom is acute testicular pain and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it is in doubt an ultrasound is helpful in ruling in or out the condition. Emergency diagnosis and treatment is required in order to save the viability of the testicle.

Signs and symptoms

Testicular torsion usually presents with an acute onset of diffuse testicular pain and tenderness of less than 6 hours of duration. There is often an absent or decreased cremasteric reflex. Many of the symptoms of testicular torsion are similar to the infection epididymitis.

Risk factors

Congenital

Conditions that allow the testicle to rotate predispose to torsion. A congenital malformation of the processus vaginalis known as the "bell-clapper deformity" accounts for 90% of all cases. In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis.

Size

A larger testicle either due to normal variation or a tumor increases the risk of torsion.

Temperature

Torsions are sometimes called "winter syndrome". This is because they often happen in winter, when it is cold outside. The scrotum of a man who has been lying in a warm bed is relaxed. When he arises, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.

Diagnosis

Immediate testing for torsion is indicated when the onset of testicular pain is sudden and/or severe. In general a doppler ultrasound should be obtained only in low suspicion cases to rule out torsion while in those cases with a convincing history and physical exam immediate surgical detorsion (Derotation) is reasonable.

Clinical exam

Prehn's sign though a classic physical exam finding has not been found to be reliable in distinguishing torsion from other causes of testicular pain such asepididymitis. In cases of true torsion the cremasteric reflex is typically absent, the scrotum is generally not very swollen, and the affected testis may have a horizontal lie.

Imaging

A doppler ultrasound scan of the scrotum is nearly 100% accurate at detecting torsion. It is identified by the absence of blood flow in the twisted testicle, which distinguishes the condition from epididymitis.

Pathophysiology

Torsion is due to a mechanical twisting process. It is also believed that torsion occurring during fetal development can lead to the so-called neonatal torsion orvanishing testis, and is one of the causes of an infant being born with monorchism (one testicle).

Treatment

With prompt diagnosis and treatment the testicle can be saved in a high number of cases. In some cases the testicle can untwist on its own or it can be manually untwisted, which can be attempted with pain relief as the guide for successful detorsion. Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of reviewed studies.

Testicular torsion is a surgical emergency that needs immediate intervention. If treated within 6 hours, there is an excellent chance (90%) of saving the testicle. Within 12 hours the rate decreases to 50%, within 24 hours is 10%, and after 24 hours the rate approaches 0. Once the testicle is dead it must be removed to prevent gangrenous infection.

Epidemiology

Torsion is most frequent among adolescents with about 65% of cases presenting between 12 – 18 years of age. It occurs in about 1 in 160 males or 1 in 4000 males per year before 25 years of age.