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Testicular torsion is a true urologic emergency. It occurs when a testicle rotates on its vascular pedicle resulting in vascular obstruction (Figure 130-1). Torsion is most common between the ages of 12 to 18.1 Age should not be considered when making the diagnosis, however, as torsion may occur in an antenate, neonate, or geriatric patient.2A history of prior orchiopexy does not negate the possibility of torsion. Presenting signs and symptoms frequently include acute and diffuse scrotal pain, scrotal swelling, a high-riding testicle, and an absent cremasteric reflex. If torsion is suspected, a Urologist should be consulted immediately and manual detorsion attempted.

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Figure 130-1
Graphic Jump Location

Torsion of the right testicle. The testicle lies horizontally and in a higher position than the normal testicle.

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The differential diagnosis of the acutely swollen or painful scrotum also includes torsion of the testicular appendage, epididymitis, orchitis, hernia, varicocele, tumor, trauma, idiopathic scrotal edema, fat necrosis, viral inflammation, and Henoch-Schönlein purpura.3,4As testicular torsion is the diagnosis requiring the most urgent action, it should be first on the differential diagnosis list. Testicular torsion may result in irreversible damage to the involved testis. It may also affect the contralateral testicle. Recent studies have examined the possible immunologic mechanism for this global effect on fertility but the exact pathophysiology has not been established.5,6

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Testicular torsion results in the obstruction of the blood supply to the testis. The venous obstruction leads to edema. This is followed by arterial obstruction that leads to testicular ischemia. Because the degree of torsion or vascular compromise cannot be quantified by current methods, the time for torsion to result in irreversible testicular damage cannot be determined.2 A complete vascular occlusion will cause a testicle to develop permanent and irreversible damage earlier than a testicle with partial vascular occlusion. The literature is variable and cites a range of 6 to 24 hours of vascular occlusion required to cause irreversible ischemic damage to a testicle.7 Most authors agree that the best outcomes are obtained with detorsion within 6 hours of symptom onset.

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Testicular torsion may be classified as extravaginal or intravaginal. Extravaginal torsion occurs primarily in neonates. The testis, epididymis, and tunica vaginalis twist together on their vertical axis because the gubernaculum has not yet become attached to the scrotal wall. It is caused by the free rotation of the testicle around the spermatic cord at a level above the tunica vaginalis. Intravaginal torsion occurs in peri- or postpubertal males and has been associated with the so-called bell-clapper deformity. In the normal scrotum, the tunica vaginalis only partially covers the epididymis and does not cover the spermatic cord. In the bell-clapper deformity, the tunica vaginalis encases the entire testicle, epididymis, and base of the spermatic cord. This allows the contents to twist and move within the ...

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