Testicular Torsion

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Basics

Description

  • Twisting of testis and spermatic cord, resulting in acute ischemia and loss of testis if unrecognized:
    • Intravaginal torsion: occurs within tunica vaginalis, only involves testis and spermatic cord
    • Extravaginal torsion: involves twisting of testis, cord, and processus vaginalis as a unit; typically seen in neonates
  • System(s) affected: reproductive

Geriatric Considerations
Rare in this age group

Pediatric Considerations
Peak incidence at age 14 years (1)[B]

Epidemiology

Incidence
  • ~1/4,000 males before age 25 years
  • Predominant age:
    • Occurs from newborn period to 7th decade
    • 65% of cases occur in 2nd decade, with peak at age 14 years (1).
    • Second peak in neonates (in utero torsion usually occurs around week 32 of gestation) (1)

Etiology and Pathophysiology

  • Twisting of spermatic cord causes venous obstruction, edema of testis, and arterial occlusion.
  • “Bell clapper” deformity is most common anatomic anomaly predisposing to intravaginal torsion:
    • Defined as a high insertion of the tunica vaginalis on the spermatic cord, resulting in increased testicular mobility within tunica vaginalis
    • Bilateral in ~80% of patients (1)[B]
  • No clear anatomic defect is associated with extravaginal testicular torsion:
    • In neonates, the tunica vaginalis is not yet well attached to scrotal wall, allowing torsion of entire testis including tunica vaginalis (1)[B].
  • Usually spontaneous and idiopathic (1)[B]
  • 20% of patients have a history of trauma.
  • 1/3 have had prior episodic testicular pain.
  • Contraction of cremaster muscle or dartos may play a role and is stimulated by trauma, exercise, cold, and sexual stimulation.
  • Increased incidence may be due to increasing weight and size of testis during pubertal development.
  • Possible alterations in testosterone levels during nocturnal sex response cycle; possible elevated testosterone levels in neonates (1)[B]
  • Testis must have inadequate, incomplete, or absent fixation within scrotum (1)[B].
  • Torsion may occur in either clockwise or counterclockwise direction.

Genetics
  • Unknown
  • Familial testicular torsion, although previously rarely reported, may involve as many as 10% of patients.

Risk Factors

  • May be more common in colder months
  • Paraplegia
  • Previous contralateral testicular torsion

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Basics

Description

  • Twisting of testis and spermatic cord, resulting in acute ischemia and loss of testis if unrecognized:
    • Intravaginal torsion: occurs within tunica vaginalis, only involves testis and spermatic cord
    • Extravaginal torsion: involves twisting of testis, cord, and processus vaginalis as a unit; typically seen in neonates
  • System(s) affected: reproductive

Geriatric Considerations
Rare in this age group

Pediatric Considerations
Peak incidence at age 14 years (1)[B]

Epidemiology

Incidence
  • ~1/4,000 males before age 25 years
  • Predominant age:
    • Occurs from newborn period to 7th decade
    • 65% of cases occur in 2nd decade, with peak at age 14 years (1).
    • Second peak in neonates (in utero torsion usually occurs around week 32 of gestation) (1)

Etiology and Pathophysiology

  • Twisting of spermatic cord causes venous obstruction, edema of testis, and arterial occlusion.
  • “Bell clapper” deformity is most common anatomic anomaly predisposing to intravaginal torsion:
    • Defined as a high insertion of the tunica vaginalis on the spermatic cord, resulting in increased testicular mobility within tunica vaginalis
    • Bilateral in ~80% of patients (1)[B]
  • No clear anatomic defect is associated with extravaginal testicular torsion:
    • In neonates, the tunica vaginalis is not yet well attached to scrotal wall, allowing torsion of entire testis including tunica vaginalis (1)[B].
  • Usually spontaneous and idiopathic (1)[B]
  • 20% of patients have a history of trauma.
  • 1/3 have had prior episodic testicular pain.
  • Contraction of cremaster muscle or dartos may play a role and is stimulated by trauma, exercise, cold, and sexual stimulation.
  • Increased incidence may be due to increasing weight and size of testis during pubertal development.
  • Possible alterations in testosterone levels during nocturnal sex response cycle; possible elevated testosterone levels in neonates (1)[B]
  • Testis must have inadequate, incomplete, or absent fixation within scrotum (1)[B].
  • Torsion may occur in either clockwise or counterclockwise direction.

Genetics
  • Unknown
  • Familial testicular torsion, although previously rarely reported, may involve as many as 10% of patients.

Risk Factors

  • May be more common in colder months
  • Paraplegia
  • Previous contralateral testicular torsion

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