Sudden onset of genital pain; testicular torsion

Is testicular torsion serious?

Testicular torsion is a medical condition when the spermatic cord, which carries blood to the testicles, becomes twisted, cutting off the blood supply.

The reduced blood flow leads to sudden pain, experienced as scrotal pain and swelling (typically in one testicle) or abdominal pain that requires prompt treatment.

Testicular torsion occurs commonly in males in their teenage years but can also happen in younger boys and adult men.

What is the role of testicles?

The testicles are two oval-shaped glands in the scrotum, with the skin sac hanging beneath the penis. The testicles are responsible for hormone production, including testosterone, which is crucial to male sexual development and reproductive function. The testicles are responsible for producing sperm.

What is a spermatic cord?

The spermatic cord is a bundle of nerves, blood vessels, and muscles that attaches the testicles to the body. When the cord becomes twisted, the blood flow to the testicle is blocked, and the testicle can become damaged or even die if left untreated.

Is testicular torsion a medical emergency?

Testicular torsion is a surgical emergency that requires immediate attention. The longer the condition goes untreated, the greater the risk of permanent damage to the testicle, ultimately leading to a dead testicle.

When does severe damage to the testicle happen?

Irreversible damage to the testicular tissue can occur within as little as 4 hours after the onset of testicular torsion symptoms. Testicular torsion requires surgery.

Who is at risk of testicular torsion?

• Age: Testicular torsion is more common in adolescent males but can also occur in boys or young men. This may be because the testicles are still developing in teenagers and may be more prone to twisting.
• Family history: If someone in your family has had testicular torsion, you may also be more likely to develop it. This could be due to genetic or shared environmental factors that increase the risk.
• Physical activity: Sports that involve a lot of twisting or sudden movements, such as basketball or soccer, can increase the risk of the spermatic cord becoming twisted.
• Anatomical factors: Certain anatomical features can increase the risk of testicular torsion. For example, Undescended testicles, which fail to move down into the scrotum during fetal development, are also at increased risk for torsion. Another known anatomical change increasing the risk of the testicle twisting is Bell clapper deformity.
• Trauma: Direct trauma to the scrotum or testicles can also lead to testicular torsion.

What is Bell clapper deformity?

Bell Clapper Deformity is a medical condition in which the testicles have an abnormal attachment. This allows the testicle to move freely within the scrotum, much like the clapper of a bell swings back and forth within the bell. This can lead to intermittent torsion, where the testicle rotates.

Genetics and inheritance play a role, but how exactly Bell Clapper Deformity happens is not fully understood.

How common is testicular torsion?

The incidence of testicular torsion is relatively rare, occurring in about 1 in 4,000 males under 25. While having a family history of testicular torsion may increase your risk slightly, it does not necessarily mean you will develop the condition.

What are the congenital factors increasing the risk of testicular torsion?

• Bell clapper deformity is a congenital condition in which the testicles are improperly anchored and can move freely. This can increase the risk of the spermatic cord becoming twisted, leading to testicular torsion.
• Undescended testicle: Some men are born with one or both testicles that fail to move down into the scrotum during fetal development. This can increase the risk of testicular torsion because the undescended testicle is not anchored as usual and is more prone to twisting.

What are the symptoms of testicular torsion? What do you feel?

• Sudden and severe testicular pain: The most common symptom of testicular torsion is sudden and severe pain in the affected testicle. The pain may start as a dull ache and become sharp and intense. Vomiting and nausea may accompany the pain, which can be constant or come in waves.
• Swelling and redness: The affected testicle may become swollen and red due to the lack of blood flow. The scrotum may also become swollen and tender to the touch.
• Changes in testicle position: Testicular torsion can cause the affected testicle to become twisted, leading to changes in its position. The testicle may be higher than usual, or it may be turned sideways or backwards.
• Abnormal testicle appearance: The affected testicle may appear twisted, enlarged, or discoloured.

It is important to note that not all cases of testicular torsion present with all of these symptoms. Some cases may only present with one or two symptoms, while others may present with several.

How is testicular torsion diagnosed?

Diagnosis of testicular torsion is based on the presenting symptoms and physical examination.

Your doctor will ask about your symptoms and medical history and physically examine your scrotum and testicles. Sudden severe pain together with any of the following swelling, redness, and changes in testicle position or appearance are strong indicators of

Scrotal ultrasound does not always pick on blocked blood flow to the testicle and can miss a testicular torsion. Still, they are not typically not used as the primary means of diagnosis.

Blood tests and urine tests are not helpful to diagnose testicular torsion.

If your doctor thinks you are experiencing testicular torsion, they will offer you a surgical exploration. This is the preferred method of diagnosis and treatment (correct testicular torsion, fix the other testicle, and if the twisted testicle is not viable, it will be removed. This is called orchiectomy.)

What are the complications of testicular torsion?

1. Damaged testicle: If testicular torsion is not treated promptly, it can lead to tissue death in the affected testicle, a condition called testicular infarction. This can cause long-term damage and may require the removal of the affected testicle. Testicular damage can also lead to reduced fertility.
2. Infertility: Testicular torsion exposes the sperm to the blood immune system. The immune system starts forming anti-sperm antibodies, which leads to reduced fertility. If the testicle needs to be removed, men can experience a lower sperm count.
3. Emotional impact: Men who experience testicular torsion may experience emotional distress due to the potential impact on fertility and sexual function. Those that have lost a testicle can explore having a testicular prosthesis down the line.
   

How is testicular torsion treated?

Surgical exploration for testicular torsion is performed to untwist the spermatic cord and restore blood flow to the affected testicle to prevent permanent damage.

The surgery is typically an emergency surgery performed under general anaesthesia and involves the following steps:

1. Incision: To perform surgery, the surgeon will make a small incision in the scrotum near the affected testicle.
2. Inspection: The surgeon will carefully inspect the affected testicle and the spermatic cord to confirm the diagnosis of testicular torsion.
3. Untwisting: If testicular torsion is confirmed, the surgeon will carefully untwist the spermatic cord to restore blood flow to the affected testicle. The twisted testicle appears bluish to purple. When untwisted, there is a flush.
4. Fixation: If the twisted testicle is viable when untwisted, it is anchored so it does not twist in the future. The surgeon will fixate on the unaffected testicle to prevent torsion from occurring in the future.
5. Closure: this is done with absorbable sutures.

Can I have testicular torsion in both testicles?

Studies have shown that the risk of contralateral (opposite side) testicular torsion after the first episode of testicular torsion is between 1% and 6%.

What are the complications of testicular torsion surgery?

1. Infection: Infection is a potential complication after any surgery, including testicular torsion surgery. Signs of infection may include fever, increased pain, redness or swelling at the surgical site, or drainage of pus.
2. Bleeding: Bleeding is a rare complication after testicular torsion surgery, but it can occur. Patients who experience excessive bleeding may require additional surgery to control the bleeding.
3. Testicular atrophy: Testicular atrophy refers to the shrinking of the affected testicle after surgery. While this is a rare complication, it may occur if blood flow to the testicle is not restored quickly enough.
4. Recurrence of torsion: In rare cases, testicular torsion may recur even after surgery. This may occur if the spermatic cord is twisted again or the fixation used to prevent torsion fails.
5. Chronic pain: Chronic pain is a potential complication after testicular torsion surgery. While this is relatively rare, some patients may experience long-term pain or discomfort after the surgery.
6. Infertility: In some cases, testicular torsion surgery may lead to infertility, particularly if both testicles are affected or if the surgery is delayed and blood flow to the affected testicle is not restored quickly enough.
   

When can I have a prosthesis?

After undergoing an orchidectomy, a testicular prosthesis can be implanted. The timing for the prosthesis placement will depend on the individual's recovery process.

It is generally advisable to wait 6-8 weeks after the orchidectomy before considering a testicular prosthesis. This waiting period allows proper surgical incision healing and resolution of any swelling or discomfort. However, the timing may vary depending on the extent of surgery and any additional treatments or complications.

How can I prevent testicular torsion?

If you have symptoms of testicular torsion, go to the emergency room to treat testicular torsion.

All intermittent testicular torsion cases can have an elective testicular fixation surgery to prevent testicular torsion.