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.
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.
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.
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.
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.
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.
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.
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.
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.
There are no conflicts of interest.
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