Testicular torsion (TT, testicular rotation) is a condition characterized by painful and testicular swelling due to disruption of the blood vessels of the testis. It is a urological emergency. If it is not intervened and corrected in time, testicular functions are lost. It is usually a one-sided situation. If it is diagnosed in the early period and surgically corrected, the testis will not be damaged. In this article, I will give general information about TT in the light of our own experiences and general literature.

What is testicular torsion?

Testicular torsion (TT) is the rotation of the structure called the spermatic cord, through which the testicular vessels pass. As a result, the vein carrying blood to the testis (testicular artery) is blocked and blood flow to the testis is stopped. As a result of the cessation of blood flow to the testis, nutrition is disrupted and the testis loses its normal functions.

TT is shown schematically in the picture.

How many types of TT are there?

TT can be classified anatomically in different ways. Treatment and clinical course are the same either way. Anatomically, there are two types of torsion according to the way it occurs:

• Intravaginal TT: Normally, the testicles are located in a membrane called tun,ka vaginalis. This membrane contains very little fluid. Thanks to this fluid, the testicles are protected against trauma. Torsion resulting from the rotation of the spermatic cord in the tunica vaginalis is known as intravaginal torsion.
• Extravaginal torsion: It is the form of torsion that occurs as a result of the spermatic cord turning around itself outside the tunica vaginalis.

At what age is it most common and how common is it?

Testicular torsion can be seen in the womb before birth and after birth at any age, including advanced age. It is seen in 65% of men between the ages of 12-18. If these cases are diagnosed and treated early, future complications can be prevented.

It occurs in 1 in 4000 people under the age of 25. It is mostly seen unilaterally and on the left. It is less common in the right testis. This disease can be seen in both testicles at a rate of 2%.

Testicular torsion in newborns and infants

TT can also be seen rarely in newborns and infants. In these cases, it is difficult to evaluate testicular blood flow with USG. Surgery is required for definitive diagnosis.

Is TT seen in testicular cancer and undescended testicular cases?

Although not very common, testicular rotation can also be seen in people with testicular cancer and undescended testicles. If patients with testicular cancer and undescended testicles have symptoms such as severe pain, nausea and vomiting, then torsion should be suspected. Normally, there is no pain in testicular cancer. If there is pain, it is necessary to suspect testicular torsion or bleeding into the cancer.

What are the causes of testicular torsion?

The causes of testicular rotation are not fully known. It is possible to list the situations that cause torsion as follows:

• Genetic causes: In these patients, the torsion is usually bilateral.
• Excessive physical activity
• Testicular trauma
• Some people may develop torsion during sleep and patients wake up with severe pain.
• Cold weather may have an effect
• May be the result of rapid growth of testicles during puberty
• Most patients have no cause.

What are the risk factors?

There are some risk factors for testicular rotation. It is more common in men with these risk factors. It is possible to rank them as follows;

• Age: It is often seen in boys aged 12-18 years.
• Genetic causes: The risk of torsion is higher in men with a family member with this disease.
• People who have had previous torsion: Some people may have mild intermittent torsion. Intermittent TT should be considered in men with intermittent testicular pain that resolves spontaneously. These people have a higher risk of developing torsion in the future.

Is the duration of treatment important?

TT is a very serious and urological emergency. In this case, there is occlusion in the vessels of the testis and impaired blood flow. The definitive treatment of the disease is surgery. With surgery, the testis is brought to its normal position and the flowing flow of the testis is corrected. Time is very important in order to get good results from the treatment. The sooner intervention is made after the onset of pain, the higher the success rate.

• If the torsion has exceeded 6 hours, the rate of testicular damage and testicular removal is high.
• In cases exceeding 12 hours, 75% of the testicles should be removed.
• It is extremely difficult to save the testis in cases of TT that exceeds 24 hours. Only about 10% of these cases can be saved with surgery.

What are the symptoms of TT?

The diagnosis of testicular rotation can be made clinically. It is possible to diagnose the disease with a good questioning and examination. The most common symptoms of this disease are:

• Sudden onset of severe pain in the testis
• Swelling in the scrotum (skin in which the testicles are located)
• Bruising, redness on the skin of the scrotum
• Pain in the lower abdomen on the torsion side
• Nausea and vomiting
• •High fever
• Frequent urination
• The testicle with torsion on examination is higher than the other
• Increased pain by manually raising the testis (Phren’s sign)
• Young children can sometimes wake up from sleep with severe pain in the testis.
• Sometimes torsion can occur after trauma to the scrotum

What are the complications of testicular rotation?

TT is an urgent urological disease. Early diagnosis and appropriate treatment should be given. If it is delayed, testicular functions will be lost and serious complications will develop in the future, since the blood supply of the testis will be impaired. These complications are:

• Testicular atrophy: If no treatment is done in the early period, the blood supply of the testis is impaired and the testis becomes smaller and its functions are adversely affected. In delayed cases, the testis should be removed.
• Infertility: Sperm cannot be produced due to the deterioration of testicular function and infertility develops in these people in the future. If the contralateral testis is normal, sperm production can continue.
• Hypogonadism: Another important function of the testis is to produce the hormone testosterone. If the torsion lasts for a long time, sufficient testosterone cannot be produced as a result of testicular damage and hypogonadism develops. If the other testicle is normal, testosterone production may be normal in the future.
• Bilateral torsion: If bilateral TT has developed and appropriate treatment has not been performed on time, these patients will develop symptoms of infertility and testosterone deficiency (hypogonadism) in the future.
• Psychological problems: If TT is not intervened in a timely manner and it is necessary to remove the testicles, these people may experience psychological problems due to testicular loss in the future.

Is it possible to avoid TT?

It is not possible to predict the future development of TT in boys. Therefore, preventive treatment against the development of torsion in the future is not necessary for every man. However, protective measures can be taken in people with a genetic predisposition for torsion. In men with a genetic predisposition for torsion, surgically testifying both testicles into the scrotum prevents future torsion.

Advice to families

It is extremely important for families to be aware of this issue. Since the disease is very rare, it is natural that families are not informed. What families need to do is to apply to a urology specialist without wasting time if their children have complaints such as pain, swelling, redness, fever, nausea and vomiting in one or both testicles.

What diseases is TT confused with?

Testicular rotation can be confused with some diseases. The doctor can distinguish between examinations and tests. The disease that this disease is most confused with is orchitis, that is, testicular inflammation. In cases where the exact differentiation of the disease cannot be made, the doctor immediately takes the patient into surgery. If there is torsion, the spermatic cord is brought to its normal position and fixed to the scrotum.

Which department deals with this disease?

TT disease is mostly seen in boys under 18 years of age. Most of these patients usually go to the pediatrics department. More conscious patients apply to the Urology outpatient clinic. Pediatricians (pediatrics) specialists also have sufficient knowledge about the disease. After examining the patient, they refer them to the urologist. Because the treatment of this disease is possible with surgery.

How is the disease diagnosed?

In order to diagnose testicular rotation, the patient undergoes a general urological examination. In addition, some radiological examinations that may help in the diagnosis are requested. It is possible to list the steps to be followed in the diagnosis as follows;

• Medical history of the patient: Patients are questioned in detail. The onset of pain and the history of trauma are investigated.
• Examination: On examination, the scrotum is edematous and painful. The pain increases when the scrotum is lifted up.
• Urinalysis: Urinalysis is not very important in the diagnosis. It gives information about urinary tract infection.
• Scrotal ultrasonography (USG): Testicular dimensions are evaluated by USG. In color Doppler USG, it is seen that the blood flow of the testicle with torsion is very reduced or completely stopped according to the degree of torsion.
• Testicular scintigraphy: Testicular scintigraphy evaluates the blood supply of the testis.
• Surgical exploration: In patients whose definitive diagnosis cannot be made, the testis is evaluated surgically. If there is torsion in the testis, it is brought to normal and fixed to the scrotum wall.

How is testicular torsion treated?

T-turn treatment is possible with surgery. There is no drug treatment. The patient should be operated as soon as possible without losing time.

• Correction of torsion and fixation to the scrotum: The definitive treatment of testicular torsion is surgery. The surgery is performed under general anesthesia. While the patient is under anesthesia, a small incision is made in the scrotum and the testis is seen. If torsion is detected, the spermatic cord is returned to its normal position (torsion is corrected) and the testis is fixed to the lower part of the scrotum.
• Identification of the contralateral testis: In case of future torsion as a preventive measure, the normal contralateral testis should also be fixed to the scrotum in the same surgery.
• Manual torsion correction: In some cases, the doctor can manually correct the torsion without surgery. However, this condition is not permanent, it is a temporary treatment. In order to avoid torsion again in the future, the testis must be surgically fixed to the scrotum.

What should be done in cases of overdue?

In order to be successful in the treatment of this disease, it should be intervened in the early period. If it is too late and there is no sign of vitality in the testis during the surgery, the testis must be removed. Because this testicle no longer has any function.

What is the success rate of the surgery?

TT surgery is a treatment method with a hundred percent success rate if it is performed on time. The surgery takes about 30 minutes. No serious complications develop after the surgery. Simple pain and wound infection can be prevented with painkillers and preventive antibiotics.

In summary; TT is a disease manifested by impaired blood flow to the testis, pain and swelling in the testis as a result of the rotation of the spermatic cord around itself. It is an urgent problem. The treatment is surgery. With surgery, the spermatic cord is brought to its normal position and the testis is fixed to the scrotum. The success rate is very high in attempts made within 6 hours. In cases exceeding 24 hours, the chance of survival of the testis is extremely low.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY