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Testicular torsion in adolescents

Shaeer, Kamal Z.; Shaeer, Osama K.; Ragab, Mohamed W.

doi: 10.1097/01.XHA.0000496449.53293.3d
Review articles

Testicular torsion is one of the common causes of acute scrotum in adolescents. Early diagnosis and proper surgical management is crucial for testicular salvage. Although testicular torsion was first described in 1840, it is one of the most common reasons for malpractice lawsuits among adolescent boys. This review article aimed to highlight all clinical, diagnostic, and management aspects of testicular torsion, emphasizing on recent updates and experimental studies in that field. We reviewed already published articles in this context using PubMed, Medical Subject Headings database, Cochrane Central Register of Controlled Trials, and Google Scholar until April 2015. We used testicular torsion and acute scrotum as keywords. Most studies on this subject were correlated to management, differential diagnosis, surgical interventions, and experimental studies in the field of minimizing ischemia–reperfusion injury. Recent publications focused on providing highly sensitive and specific diagnostic methods and on improving the testicular salvage rate.

Department of Andrology, Faculty of Medicine, Cairo University, Cairo, Egypt

Correspondence to Mohamed W. Ragab, MSc, Department of Andrology, Faculty of Medicine, Cairo University, Cairo 12622, Egypt Tel: +20 127 990 9997; e-mail:

Received October 25, 2015

Accepted August 14, 2016

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Historical background

In Greek mythology, it was believed that Gods would shoot young healthy men with arrows, which would cause pain, followed by testicular atrophy. The condition of sudden pain, detected by palpation as a tender scrotal swelling and progression to testicular atrophy, was highlighted early in history as torsion of the spermatic cord 1.

In 1776, Hunter mentioned what can be considered a case of left testicular torsion in an 18-year-old man who presented with the typical clinical presentation of acute scrotum. After a few weeks the testis atrophied ‘to the size of a horse bean.’ One year later, torsion occurred on the right side, followed by ipsilateral atrophy 2. The first reported case of torsion of an undescended testis was published in 1840 by the French psychiatrist Louis Delasiauve 3. Lauenstein 4 was the first to publish original and schematic illustrations of testicular torsion and also the first to classify it in 1894.

In 1922, torsion of the testicular appendix was described by Colt 5. Further, the first illustration was made by Mouchet 6.

Surprisingly, with such a long history of identification and development of different diagnostic technologies, testicular torsion is the third most common reason for malpractice lawsuits in adolescent boys in the USA 7.

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Incidence of testicular torsion is bimodal, with the first peak occurring in adolescent boys aged 12–18 years and a second less common peak being in the first year of life 8. However, it can be seen in any age group. Intravaginal torsion has been reported in as young as a newborn baby and in as old as a 77-year-old man. Sixty-two percent of cases occur in patients aged 12–18 years and 89% below the age of 25 years 9. It is estimated that 1/4000 men under the age of 25 will have torsion of the testis 10.

Testicular torsion is the cause of 16–39.5% of cases of acute scrotum in childhood 11. Testicular torsion is the most common cause of acute scrotum in the first year of life (83%). From the age of 3–13 years, the most common cause is torsion of testicular appendages. In the male population over 17 years, epididymitis is the most common cause of acute scrotum (75%) 12.

Regarding torsion of appendages, about 82% of cases occur between the ages of 7 and 14 years. However, it has been reported in the first to fifth decade of life 13–15. The testicular appendix is involved in 92% of cases, the epididymal appendix in 7%, the paradidymis in 0.6%, and the vas aberrans in 0.3% of cases 16.

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According to its relation to the tunica vaginalis, testicular torsion is classified into two types. The first type, which is intravaginal torsion, occurs within the tunica vaginalis and is the most common type. The second type of testicular torsion is termed extravaginal torsion. It occurs in newborns when the testis and its gubernaculum can rotate freely in the scrotum 17.

Intravaginal torsion requires an anatomical predisposition for torsion. Torsion is triggered by an initiating force. Torsion occurs in the direction of the internal rotation in 71–100% of cases 18,19. The degree of rotation ranges from 180° to 1440° 14. A single study showed a significantly higher degree of rotation (mean=585°) in patients aged 21 years or more compared with that in patients younger than 21 years of age (mean=431°) 20. This rotation compromises the blood flow of the testis and obstructs the veins of the cord first on account of their thinner walls. Bound by the connective tissue coverings of the spermatic cord, pressure within the congested veins increases pressure within the cord, ending in obstruction of arterial inflow, even if the torsion is unable to occlude the artery directly 21. Direct arterial occlusion requires multiple twists 22.Testicular torsion induces ischemic injury, and torsion repair induces an ischemia–reperfusion (I/R) injury that disrupts the testicular spermatogenic and endocrinal functions by different mechanisms including induction of apoptosis, activation of neutrophils, upregulation of endothelial cell adhesion molecules and inflammatory cytokines, release of intracellular Ca2+, and generation of reactive oxygen species (ROS) 23.

Testicular salvage rate depends on the degree of rotation of the spermatic cord and the duration of spermatic cord torsion. Kolettis et al.24 found in a canine model study that 90° rotation of the spermatic cord led to a pathological picture of necrosis within 7 days. Similar findings were obtained by 360° rotation within 12–24 h. A 1440° rotation of the cord resulted in complete necrosis of the testicle within 2 h.

Early management of testicular torsion improves the salvage rate of the affected testis. In a large single institution series that involved 624 cases, viability at exploration in relation to 0-6, 7-12 and >48 hours of spermatic cord torsion was found to be 98%, 90% and 8% respectively 9. In a meta-analysis that involved 1140 patients from 22 reports and another one that involved 535 patients in eight series, Visser and Heyns 26 similar results were found.

The urgent versus elective management of cases of delayed presentation of torsion is a debatable point. These reports, as well as other reports 27–29, provide strong evidence against the misconception that testicular torsion presenting after 6 h should not be treated as an emergency as it is not salvageable.

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Anatomical predisposition for testicular torsion

Intravaginal testicular torsion is predisposed to the presence of bell-clapper deformity, spiral arrangement, and low insertion of the cremasteric muscle and abnormal junction between the epididymis and the testis, forming a mesorchium 13. Bell-clapper deformity, which is proximal extension of the tunica vaginalis around the spermatic cord, is found in 12% of autopsies, and is bilateral in 66% of cases, suggesting that it is a common deformity in humans and its prevalence is more than torsion 30. Against the myth that bell-clapper deformity is present invariably in intravaginal testicular torsion, bell-clapper deformity was found in 71–75% of cases of intravaginal testicular torsion 18,31. Testicular torsion occurs ten times more in patients with undescended testes 14. Before 1952, 60% of all cases of torsion were seen along with cryptorchidism. These numbers decreased sharply because of routine orchiopexy during surgical repair of undescended testis 1. Extravaginal torsion, which is found in neonates, occurs because of free mobility of the neonatal tunica vaginalis and its contents inside the scrotum 14,32 (Figs 1 and 2).

Figure 1

Figure 1

Figure 2

Figure 2

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Initiating force

Cremasteric spasm, which holds the testis in the torsed position, was found to be associated with trauma, vigorous exercise, and cold weather, and to occur even during sleep 33. The peripubertal increase in testicular size relative to the spermatic cord may contribute to torsion by adding a greater momentum to any twisting action 14. The same mechanism may explain the occurrence of testicular torsion in several reported cases of patients on human chorionic gonadotrophin therapy 34,35.

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Genetic background of testicular torsion

A genetic basis for testicular torsion has been suspected after numerous published reports of familial testicular torsion appeared 36–39.

A meta-analysis showed that up to 10% of testicular torsion patients have a positive family history in a first-degree relative, with high incidence of bilateral testicular torsion in familial cases (37%) 39.

INSL3 hormone and its receptor RXLF2 have been suggested as candidate genes for testicular torsion. INSL3 is a hormone secreted by Leydig cells and regulates the growth and differentiation of the gubernaculum; thus, it mediates intra-abdominal testicular descent 40. INSL3 knock-out mice invariably manifest with intra-abdominal bilateral cryptorchidism with subsequent heat-induced atrophy of the testes in adulthood, and spontaneous testicular torsion, which occurred peripubertally in most of the cases 41.

In contrast, in a study that involved 39 male patients with surgically confirmed testicular torsion (11 neonatal, 21 peripubertal, and seven pubertal), a positive family history of torsion was present in 29% of neonatal and 33% of peripubertal cases. Nonsignificant mutations in INSL3 or RXFP2 could be linked to testicular torsion 42. However, this ligand-receptor signaling system may be still linked to testicular torsion by another level of regulation.

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Clinical features

Testicular torsion should be suspected in neonates and peripubertal boys presenting with acute scrotum; torsion of a testicular appendage is more common in prepubertal boys, and epididymitis most often develops in postpubertal boys 43.

Testicular torsion pain is characterized by being acute and severe, and begins to diminish after 6 h 44. Gradual moderate pain is more suggestive of epididymitis or appendiceal torsion 43. Abdominal pain may be the presenting symptom in 5–25% of patients 9,44. Nausea and vomiting may be present in 26–60% of testicular torsion cases. Nausea has a positive predictive value of 96% and vomiting 98% for torsion, but both have lower sensitivity 16,45. Urinary complaints are not pathognomonic for genital tract infection and should not be used to exclude testicular torsion. Urinary symptoms are present in 5–7% of patients with testicular torsion. The symptoms are typically slight frequency and dysuria. Interestingly, urinary complaints are also found in 7% of cases with acute epididymitis 9,31. History of previous episodes of similar pain (prophetic pain) that resolved spontaneously is present in 11–47% of patients, suggesting intermittent torsion with spontaneous detorsion 16,31.

Cremasteric reflex is a superficial skin reflex mediated by ilioinguinal and genitofemoral nerve roots (L1–L2). It is elicited by stroking the medial upper thigh, and a positive reflex results in contraction of cremastric muscle and elevation of the ipsilateral testis. A point of controversy is that cremastric reflex is absent in 100% in the torsed side according to one report 46. Several reports confirmed torsion of the testis with a normal cremasteric reflex 47,48 with a sensitivity of 60% and specificity of 67% for torsion of the testis 35. A drawn-up testis is present in 26–80% of cases of testicular torsion 16,35. Between 25 and 90% of patients with torsion will have an abnormal lie of the contralateral testis (Angell’s sign). Fever is present in 8–41% of cases with testicular torsion and has a bad prognosis regarding testicular viability 9,49,50. Scrotal edema and induration also denote bad prognosis and are associated with torsion for more than 12 h 51,52.

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Diagnostic imaging

Although some cases of testicular torsion may have pathognomonic history or clinical examination findings, color Doppler ultrasound (CDU) is still the first-line radiological diagnostic tool for a patient presenting with acute scrotum to exclude testicular torsion 53. The most important CDU finding is absence of any detectable perfusion of the affected testis 10. Relying on history and clinical examination alone is inaccurate as there is a high probability of misdiagnosis. According to a retrospective review of 204 patients presenting with acute scrotum, relaying on history and clinical examination alone resulted in misdiagnosis of five cases of testicular torsion and the preoperative diagnosis was accurate only in 80% of operated cases 54. CDU is currently the diagnostic tool of choice in suspected cases, as it is easy to perform, is readily available, and provides information that could exclude other conditions such as epididymo-orchitis. However, it is an operator-dependent procedure, and sometimes normal blood flow is not detected in small-sized untorsed testes. The presence of blood flow does not exclude torsion 55–57. Testicular salvage after detorsion can be predicted by color Doppler ultrasonography; parenchymal heterogeneity of the testicular echotexture and absence of testicular blood flow indicate late torsion and testicular nonviability 58.

Lam et al.59 reported a sensitivity of 69.2%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 97.5% in the diagnosis of testicular torsion by CDU. In 323 patients who had negative ultrasound findings, 29 were surgically explored on a clinical basis. Four of these 323 patients (1.2%) were diagnosed intraoperatively as testicular torsion 59.

Lower diagnostic values were reported by Kalfa et al.60, who published a multicenter study that involved 208 patients with testicular torsion proven by surgical exploration. Testicular torsion was misdiagnosed by CDU in 50 cases (24%). Kalfa et al.60 compared these results with the results of high-resolution ultrasonography in 919 patients aged 1–18 years (mean=9) for the direct visualization of the torsion of the spermatic cord as a spiral twist of the cord resembling snail shell or ‘whirlpool sign’. Testicular torsion was diagnosed in 199 of 208 patients (96%). Testicular torsion was excluded by finding linear cord for all other causes of acute scrotum (711 patients) with a specificity of 99% 60,61.

Near-infrared spectroscopy is a more recent noninvasive technology that is based on utilizing infrared light to obtain transcutaneous monitoring of deep tissue oxygen saturation. In its pilot study for using this technology in the assessment of acute scrotum, near-infrared spectroscopy identified all surgically confirmed cases of testicular torsion 62.

Other diagnostic modalities such as scintigraphy 63–66 and scrotal dynamic contrast-enhanced subtraction MRI 67 may be used when testicular torsion is unlikely but cannot be excluded. Scintigraphy is carried out using technetium-99m to assess testicular perfusion. It has been used since 1973 63,64. Testicular torsion is represented by a cold spot of no isotope uptake with a hot perimeter of relatively increased uptake (halo sign) 64. A similar picture may be present in hematoma, abscess, and tumors of the testis. However, those tools are not always available and may cause delay for emergency intervention 54.

On the laboratory level, a recent animal model study suggested that plasma D-dimer level can be used as a diagnostic marker of testicular torsion 68.

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Differential diagnosis

In any case presenting with acute scrotum, testicular torsion should be suspected and excluded. In the first year of life, testicular torsion is considered the most common cause of acute scrotum (83%). However, some studies have found that epididymo-orchitis is present in 69% of cases and testicular torsion in 31% of cases of acute scrotum in the first year of life 69. Among male patients aged 3–13 years, the most common cause of acute scrotum is torsion of the testicular appendages. After the age of 17 years, epididymitis is considered the most common cause 12. Differential diagnosis of acute scrotum is summarized in Table 1.

Table 1

Table 1

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Management of testicular torsion

Immediate surgical exploration is indicated in all patients who presented with testicular torsion within 24 h of symptom onset. As mentioned before, testicular salvage rates decrease with increased duration of testicular torsion. Early detorsion (duration of torsion<13 h) was found to preserve fertility 82. In patients with neglected testicular torsion (duration of torsion>24 h) semielective exploration is indicated. Immediate surgery is indicated in all cases of acute solitary testis 26,82,83. Torsion of the appendix testis is managed conservatively by anti-inflammatory and analgesics 43. Surgical exploration is preserved for equivocal cases 84.

Scrotal cooling was suggested before surgical exploration 12 as it was found to preserve the testicular function 85.

Exploration of both hemiscrotum contents can be performed through a single median raphe incision. When the torsed testis is obviously necrotic, it should be removed. Equivocal testes should be wrapped in warm moist saline gauze for 5–10 min and then reassessed for testicular viability. Viable testes are detorsed and fixed. Routinely, contralateral fixation should be done 86. Contralateral fixation could be done either by three nonabsorbable fixation or by dartos poche 87,88.

One study suggested that further testicular damage occurs after detorsion because of the so-called ‘testicular compartment syndrome’; increased intratesticular pressure against the tough tunica albuginea leads to decreased perfusion to the testis and further ischemic injury 89. Kutikov and colleagues proposed a novel technique to avoid ‘testicular compartment syndrome’ by making an incision over the tunica albuginea, in a similar manner to fasciotomy, with placement of a tunica vaginalis patch during detorsion. This should allow for edema to ensue without increasing the compartmental pressure 89–91.

Manual detorsion is a simple and organ-saving procedure that can be performed with or without anesthesia. It should initially be done by outwards (like opening book) rotation of the testis unless the pain increases, or if there is obvious resistance, in which case rotation to the opposite side should be tried. Success is defined as immediate relief from pain 92. It can be done under the guidance of CDU 19. It is considered a temporary measure; residual torsion is present in up to 28% of cases. However, this maneuver has up to 80% success rate 45,92.

In this context, obtaining consent from adults or parents of minors regarding misdiagnosis of testicular appendix torsion or epididymo-orchitis as testicular torsion or necessity of orchiectomy of delayed diagnosed torsed testis is of importance.

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Drugs used to minimize ischemia–reperfusion injury

Many recent publications have focused on minimizing testicular damage induced by I/R injury after testicular torsion. Germ cell apoptosis and DNA damage is mediated by several mechanisms such as neutrophil recruitment and release of ROS such as superoxide dismutase, glutathione peroxidase, and malondialdehyde. ROS scavengers have been hypothesized to have a protective effect against I/R injury following surgical correction of testicular torsion. However, all conducted studies were performed on a rat model 61,93.

Sildenafil, vardenafil, and taladafil, which are phosphodiestrase-5 inhibitors; were injected intraperitoneally after intiation of experimental testicular torsion. Testicular tissue levels of malondialdehyde and nitric oxide synthase expression were significantly lower and total testicular antioxidant levels were higher in rats given medication as compared with those that simply underwent torsion/detorsion 94–96. Rosuvastatin is an antihyperlipidemic drug with anti-inflammatory and tissue protective effects. In a single study, it was found that when rosuvastatin was injected intraperitoneally after intiation of testicular torsion, testicular microvascular perfusion was increased 97. The use of apocynin (NADPH oxidase inhibitor) was found to decrease free radical generation and increase antioxidant protective effects on testicular tissues against I/R injury in one study 98. Polyadenosine diphosphate-ribose polymerase inhibitors such as nicotinamide, 3-aminobenzamide, 1,5-dihydroxyisoquinoline, and 4-amino-1,8-naphthalimide were found to inhibit poly (ADP-ribose) polymerase, which is one of the enzymes that play a role in testicular damage caused by I/R 99. Thymoquinone is a phytochemical compound found in the plant Nigella sativa. Thymoquinone significantly reduces the apoptotic index, active-caspase 3, and Bax expression 93. Coenzyme Q10 is an oil-soluble vitamin-like substance that is present in eukaryotic cells, mainly in the mitochondria. It acts as an antioxidant and plays a role in the electron transport chain. The use of coenzyme Q10 before reperfusion resulted in significant decrease in products of testicular lipid peroxidation; inducible nitric oxide synthase and endothelial nitric oxide synthase decreased, leading to minimization of germ cell-specific apoptosis 100.

Other drugs that have been studied in rat models of testicular torsion and showed promising outcome include lycopene 101, ginkgo biloba 102, melatonin 103, N-acetylcysteine 104, and erythropoietin 105.

Local injection of mesenchymal stem cells has been investigated in the protection of testicular torsion-induced germ cell injury. In a study by Hsiao et al.106, local injections of mesenchymal stem cells from human orbital fat tissues n a rat model minimized torsion-induced germ cell apoptosis and oxidative stress compared with the control group.

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Future perspectives

Recognition of certain genetic defects that predispose to testicular torsion is important for therapeutic development, and prophylactic orchiopexy may be considered once those genes are discovered.

Advances in diagnostic technologies may also help to provide a highly specific and sensitive technology that could minimize unnecessary surgical exploration and misdiagnosed testicular torsion.

Several recent studies have shown promising effects of certain medications in minimizing I/R injury in rat models. Studies that test the efficacy and safety of these medications on humans should be among our priorities.

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Conflicts of interest

There are no conflicts of interest.

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    acute scrotum; acute scrotal pain; testicular torsion

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