Testicular Torsion
Lauren P. Shapiro
Torsion was first described in 1840 by Delasiauve, yet it was not discussed as a problem until 1907 when Rigby and Russell published work on the subject in Lancet.
Later, Colt reported torsion of the appendix testis in 1922.
Testicular torsion, twisting of the testis and spermatic cord, is an acute and serious diagnosis affecting the scrotum and its contents, which can result in the loss of a child’s testicle.
The loss of the testicle is due to complete obstruction of the testicular vasculature resulting in infarction.
RELEVANT ANATOMY
The testicle is covered by the tunica vaginalis, which is encased by a capsule termed the “tunica albuginea.”
The tunica vaginalis attaches to the posterolateral surface of the testis, allowing for restriction of mobility of the testicle within the scrotum.
The 2 types of testicular torsion, extravaginal and intravaginal, involve the spermatic cord but differ at their proximity to the tunica vaginalis (Figure 42.1).
The testicle is secured to the scrotum by the gubernaculum distally.
EPIDEMIOLOGY AND ETIOLOGY
There are 2 types of testicular torsion: extravaginal and intravaginal.
The extravaginal type is seen more often in neonates, which is caused by torsion of the spermatic cord proximal to the tunica vaginalis attachment at the level of the external inguinal ring.1,2
The intravaginal type is overall more common in children and adolescents and is secondary to a deformity termed the “bell clapper.”1,2,3
The “bell clapper” deformity involves the tunica vaginalis, which joins proximal on the spermatic cord, allowing the testicle to twist freely in the scrotum.
The cord twists inside the tunica vaginalis.
The abnormal fixation of the testis within the tunica vaginalis has an incidence as high as 12%.3
Testicular torsion affects 3.8 per 100 000 males younger than 18 years each year and accounts for 10% to 15% of acute scrotal disease in children.4
 Figure 42.1 Types of testicular torsion. A, Schematic illustration of intravaginal testicular torsion. B, Schematic illustration of extravaginal testicular torsion. (Reprinted with permission from Kawamura DM, Nolan TD, eds. Diagnostic Medical Sonography: Abdomen and Superficial Structures. 4th ed. Philadelphia, PA: Wolters Kluwer; 2018). |
CLINICAL PRESENTATION
Classic presentation: an otherwise healthy baby or adolescent who presents with sudden onset of acute, unilateral pain in the scrotum or testicle with associated erythema and swelling (Figure 42.2).
This pain may present as inguinal or lower abdominal pain with or without radiation to the scrotum with the affected testis being very tender to palpation.
The symptoms are often accompanied by nausea and vomiting.
If episodes of intermittent testicular pain are present, this may suggest occurrences of torsion and spontaneous detorsion.
Physical examination may reveal a testicle riding high in the groin with an absent cremasteric reflex.
 Figure 42.2 Adolescent with clinical findings of testicular torsion. (Reprinted with permission from Chung EK, Atkinson-McEvoy LR, Lai NL, Terry M, eds. Visual Diagnosis and Treatment in Pediatrics. 3rd ed. Philadelphia, PA: Wolters Kluwer Health; 2015). |
DIAGNOSIS
Laboratory Findings
Diagnosis of testicular torsion is performed via mostly clinical presentation with additional imaging.
