Torsion of the testis results from twisting of the spermatic cord that compromises testicular perfusion, resulting in infarction. These ischemic changes can affect testicular morphology and fertility, even in the absence of necrosis requiring orchiectomy. Once torsion develops, there appears to be a 4–8 hour window before significant, irreversible damage occurs. The probability of testicular salvage declines significantly beyond 6 hours ( Table 51.2 ). ^, However, emergent surgical exploration is typically indicated even beyond this window because testicular viability becomes increasingly difficult to predict. Recent studies nevertheless suggest that duration of symptoms and degree of torsion at exploration can be utilized to predict testicular salvageability. ^, The mean duration of symptoms for viable versus nonsalvageable testes were 6.2 versus 13.4 hours, respectively, with a mean degree of twisting at exploration of 375 versus 529°, respectively.

Patients presenting with testicular torsion typically report sudden onset, severe, unilateral pain in the testis, lower thigh, or lower abdomen. This pain is often associated with nausea and vomiting. Episodes of intermittent testicular pain may precede the acute presentation, suggesting prior incomplete torsion and detorsion. A familial pattern of testicular torsion has more recently been confirmed and may span generations. This is an important consideration when obtaining a family history and should be included in family counseling with regard to future episodes of torsion in other male family members as salvage rates in familial torsion are surprisingly lower than in nonfamilial cases. ^,

Physical examination may reveal an enlarged testis that is retracted up toward the inguinal region with a transverse orientation and an anteriorly located epididymis. However, it is usually difficult to obtain an adequate exam due to generalized scrotal pain and tenderness. In contrast, focal tenderness at the superior pole of the testis or along the epididymis is often found with a torsed appendix testis or epididymitis. Depending on the duration of the testicular torsion, the hemiscrotum can show varying degrees of swelling and erythema, which may obliterate landmarks and make the examination more difficult ( Fig. 51.2 ). Loss of the cremasteric reflex is typical but presence of the reflex does not exclude torsion. ^,

This 13-year-old patient had a 48-hour history of right testicular pain that began when he was riding his bicycle, hit a bump, and immediately felt pain in his right testis. Examination shows an enlarged right hemiscrotum (A). His right testis is firm, edematous, and tender to touch. He was taken emergently to the operating room, and a midline scrotal raphe incision was made. He was found to have a bell-clapper deformity on both sides (B). The right testis was clearly nonviable and was removed after approximately 20 minutes of observation, during which time left orchiopexy was performed. He recovered uneventfully and was discharged.

The age distribution of testicular torsion is thought to be bimodal, with extravaginal torsion predominating in neonates and intravaginal torsion being more common in adolescent patients after puberty. Intravaginal torsion is more common and refers to twisting of the spermatic cord within the tunica vaginalis. Normally, the posterior aspect of the testicle and epididymis are adherent to the tunica vaginalis, fixing it to the dartos layers of the scrotum with a vertical lie. Abnormal fixation occurs when the tunica vaginalis attaches more proximally on the spermatic cord, creating a long mesorchium around which the testis can twist. The testis will then lie horizontally, and the pendulous testis is vulnerable to twisting with leg movement or cremasteric contraction. This anatomic variant is classically described as the “bell-clapper” deformity ( Fig. 51.3 ) and has an incidence as high as 12% in cadaveric studies. Often, it is bilateral. It is theorized that torsion occurs in the adolescent period when the testis is growing rapidly during puberty and increase in its mass predisposes the testis to spin on an axis. This same concept describes an increased risk of torsion after testicular trauma or with testicular malignancy. ^,

Bell-clapper deformity. The tunica vaginalis inserts very high on the spermatic cord, which predisposes to testicular torsion.

Extravaginal torsion typically occurs in the antenatal or neonatal period and is thought to arise because the tunica vaginalis is not firmly fixed to the dartos layer of the scrotum, allowing the testis and tunica to spin on their vascular pedicle ( Fig. 51.4 ). ^, Perinatal testicular torsion incidence rates are low and rates of testicular salvage remain poor at 0%–44%. ^{, ,} The term “perinatal torsion” encompasses both prenatal and postnatal events, with most events (75%) occurring prenatally. Distinguishing between the two types can be difficult but it affects the timing of operation. Prenatal torsion presents as a hard, nontender scrotal mass noted at birth, usually with underlying dark skin discoloration and fixation of the skin to the mass. These findings suggest testicular infarction secondary to a prior torsion. Postnatal torsion presents as an acutely inflamed scrotum with erythema and tenderness ( Fig. 51.4 ). The scrotum is often reported as normal at delivery, suggesting an acute postnatal event. This diagnosis requires emergent exploration with detorsion and bilateral fixation, with salvage rates reported as high as 40%–50%, which is similar to torsion later in life. ^{, ,}

Shortly after birth, this newborn was found to have an enlarged and erythematous right hemiscrotum (A). It was unclear whether the right hemiscrotum was enlarged at the time of birth. The baby underwent scrotal exploration through a median raphe incision and was found to have an extravaginal testicular torsion (B). The testis is enveloped by the tunica vaginalis, and the entire complex has twisted.

The timing of exploration for prenatal torsion has been controversial. Some surgeons believe exploration is not indicated because of negligible salvage rates and increased neonatal anesthetic risks. ^, However, this approach is challenged by reports of asynchronous torsion with loss of the remaining contralateral testis. ^{, ,} Furthermore, some speculate that if the torsion were to have occurred at or just prior to delivery, testicular salvage may be possible. One series of 30 neonates with torsion who were explored within 6 hours of birth found two testes that could be salvaged and demonstrated normal growth 1 year later. Therefore, many surgeons have become more aggressive with earlier exploration of these infarcted testes to fix the contralateral side and prevent the potential for bilateral torsion.

Treatment

High suspicion for testicular torsion mandates surgical exploration. Exploration is typically performed using a median raphe scrotal incision. The symptomatic hemiscrotum is entered and the testis is delivered and detorsed. If there is concern for ischemia, the affected testis can be placed in warm, moist sponges to allow for reperfusion while the contralateral hemiscrotum is explored. During this time, the contralateral testis can be assessed by creating a window in the tunica.

Upon entry into the contralateral hemiscrotum, a subdartos pouch should be created. The testis should be pulled down into the scrotum, taking care to ensure the spermatic cord is not twisted and that the testis is in proper orientation. The testis should then be fixed in place to the dependent portion of the scrotum with absorbable sutures preferably using a three-point fixation technique.

Attention is then turned back to the affected testis. If the testis is clearly nonviable, it may be removed. One argument for orchiectomy was to avoid potential damage to the contralateral testis from the formation of antisperm antibodies. However, there is conflicting evidence, both on whether or not these autoantibodies are present, and if present, their effect on fertility/function. If the torsed testis becomes reperfused or is bleeding from the cut surface, it should be fixed in the same manner as the contralateral testis. Several centers have described decompression of the testicular compartment on compromised gonads by incising the tunica albuginea and covering it with a tunica vaginalis patch. A subset of compromised testes seems to be salvageable by these maneuvers. Although this technique may benefit testicular survival, the impact of this alteration of a “privileged site” on ultimate fertility, given the potential for formation of antisperm antibodies, has dampened enthusiasm in the setting of a normal contralateral testis. Bilateral fixation reduces the probability of torsion in the future, but cases of torsion after fixation have been described. Any patient with symptoms of testicular torsion should be evaluated and managed appropriately, regardless of whether previous fixation was performed.

If testicular torsion is suspected but a delay to the operating room is unavoidable, manual detorsion can be attempted. Detorsion is performed by grasping the testicle and performing a medial to lateral, “open book” rotation within the scrotum. This will be the correct direction in two-thirds of patients. If successful, the testis will drop lower in the scrotum and the patient will report sudden pain relief. If the initial attempt is unsuccessful, an attempt in the reverse direction may be warranted. In an observational study of 133 patients, manual detorsion was attempted in 76 patients (57.1%) and was successful in 72 (95.1%), with patients who underwent successful detorsion demonstrating improved testicular salvage rates relative to patients in whom salvage was not attempted or successful (97% vs. 75%, respectively). Although these maneuvers may decrease the degree of ischemia, prompt exploration and fixation remain mandatory because the detorsion may not be complete and/or torsion can recur ( Fig. 51.5 ).

This 15-year-old patient developed an episode of left testicular torsion 2 years prior to this presentation. The torsed left testis was able to be detorsed manually, but the patient did not undergo orchiopexy or follow-up. Two years later, he presented with similar symptoms and was taken to the operating room, where he was found to have testicular torsion and the testis was detorsed. After 30 minutes of placing the testis in warm soaks, the vasculature improved to a “borderline” state, and the testis was pexed. A follow-up ultrasound study 1 month later showed the testis was two-thirds the size that was seen on the preoperative ultrasound. The blood flow to the testis was normal, but there was no internal flow within the testis.