Makindo Medical Notes

⚠️ Testicular torsion is a surgical emergency. - Affects ~1 in 4,000 young men (most common in adolescents, but can occur at any age). - If untreated, infarction and atrophy of the testis occurs, risking infertility.

ℹ️ About

• Commonest cause of acute scrotum in adolescents.
• Occurs in ~1/4000 boys, but can affect neonates and older men.
• Ischaemia begins within 4–6 hrs → irreversible necrosis by ~12 hrs.
• Needs same-day surgical exploration without delay.

⚠️ Risks

• 10× risk in cryptorchidism (undescended testis)
• “Bell clapper deformity” → tunica vaginalis abnormally high, testis rotates freely
• Groin trauma
• Rapid pubertal growth

🧬 Aetiology

• Rotation of the spermatic cord → obstructs venous drainage first → oedema → impaired arterial inflow → infarction.
• Pathology worsens with time – hence strict time-critical diagnosis.

🩺 Clinical Presentation

• ⏱️ Sudden severe testicular pain (often waking from sleep)
• 🤢 Nausea, vomiting, abdominal pain
• 👀 High-riding testis, transverse lie, absent cremasteric reflex
• Red, swollen hemiscrotum
• Sometimes haematospermia

🔎 Investigations

• FBC, U&E, CRP → supportive, excludes infection
• Urine dip/culture → rule out epididymo-orchitis
• Doppler USS: sensitivity ~97% if arterial flow seen – but do NOT delay theatre if torsion suspected clinically

📋 Differentials (Acute Scrotum)

• ❌ Epididymo-orchitis (gradual onset, dysuria, systemic features)
• ❌ Trauma, haematoma
• ❌ Inguinal hernia, hydrocele, testicular tumour
• ❌ Vasculitis (e.g., Henoch–Schönlein purpura)

🛠️ Management

• 🚑 Urgent admission, IV fluids, strong analgesia
• 🖐️ Manual detorsion (“open book” method) can be attempted if immediate theatre unavailable, but does not replace surgery
• ⏱️ Testicular survival:
  • <6 hrs: ~90% viable
  • 6–12 hrs: ~50%
  • >24 hrs: <10%
• 🔪 Surgery: exploration, untwist testis, bilateral orchidopexy (fix both sides)
• ⚰️ Non-viable testis → orchidectomy (to prevent abscess, antisperm antibodies)

📚 Reference

• Testicular Torsion – Review

Case – Acute scrotum (testicular torsion)

A 15-year-old wakes at 3am with sudden, severe unilateral testicular pain radiating to the groin, with nausea and vomiting. On exam the testis is high-riding and horizontal, exquisitely tender, with an absent cremasteric reflex; no fever or urinary symptoms. Torsion is a surgical emergency—do not delay theatre for imaging (Doppler USS only if diagnosis is truly equivocal). Give analgesia, antiemetic, keep NBM, call urology for urgent scrotal exploration; perform detorsion and bilateral orchidopexy (fix contralateral side), or orchidectomy if non-viable. Emphasise the critical 4–6 hour window for testicular salvage and document time of onset and decision to operate.