|Year : 2013 | Volume
| Issue : 1 | Page : 61-63
Intermittent testicular torsion in an adult: A case report and review of the literature
Suryapratap Singh1, Saranjeet Singh Bedi2
1 Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Department of Neurology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
|Date of Web Publication||29-May-2013|
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Testicular torsion is an acute vascular event in which the spermatic cord becomes twisted on its axis, such that the blood flowings to and/or from the testicle becomes impeded. This results in ischemic injury and infarction. Testicular torsion in adulthood is relatively unusual and has a higher morbidity rate. Any delay in the diagnosis can lead to the loss of the spermatogenic function of the testis and an increased risk of orchidectomy. Closed reduction is the initial treatment of choice. Open surgical reduction is recommended for possible testicular torsion or rupture.
Keywords: Color Doppler, orchidectomy, testis, torsion, ultrasonography
|How to cite this article:|
Singh S, Bedi SS. Intermittent testicular torsion in an adult: A case report and review of the literature. Saudi J Health Sci 2013;2:61-3
| Introduction|| |
Testicular torsion was first described by Delasiauve in 1840. It was not widely regarded as a significant problem until 1907, when Rigby and Russell published their work on torsion of the testis in Lancet. The first description of neonatal torsion was described by Taylor in 1897. Subsequently, Colt reported torsion of the appendix testis in 1922. ,,
Testicular torsion presents as an acute onset of severe scrotal pain, commonly associated with scrotal swelling and erythema. Nausea and vomiting are common, as are local scrotal redness and pain. The condition may result in loss of the testis.
The success of management of such patients depends on early consultation on part of the patient, correct diagnosis by the doctor at first consultation and urgent surgical exploration of the affected testis. ,
| Case Report|| |
A 37-year adult male patient presented with gradual enlargement of the left scrotum associated with minimal local and abdominal discomfort for last two months. He reported 3-4 similar episodes in the past 1 month and was prescribed analgesics and antibiotics. His general and systemic examination was unremarkable. On local examination, there was palpable, 6 × 8 cm hard testicular swelling with preserved testicular sensations. Overlying scrotal skin was free and there was no local rise of temperature. There was slightly thickened and tender left spermatic cord. Hematological investigations were normal except for mild leukocytosis. Urine examination was normal. A colored Doppler ultrasound of the scrotum was suggestive of torsion of left testes and there were no signs of viability. The opposite testis and intra-abdominal examination were normal. An informed consent was taken for exploration with possible removal of involved testis and fixation (orchidopexy) of the other testis. On exploration, there was an intra-vaginal left testicular torsion with double knotting and nonviable testes. The epididymis was attached to the testes at the head and tail only [Figure 1]. A high left orchidectomy and right orchidopexy was performed. Histopathological examination revealed a massively necrotic testicular structure. The patient did well postoperatively.
|Figure 1: Photograph of the specimen showing torsion of testis with double knotting at the apex|
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| Discussion|| |
Testicular torsion is described as the twisting of the spermatic cord resulting in acute pain and ischemia. Most commonly testicular torsion occurs due to anatomic anomalies of tunica vaginalis and epididymis that allow excessive testicular mobility inside the scrotum, and intravaginal torsion (bell clapper deformity) being the most frequent type. , Testicular torsion can occur at any age; it is more common than testicular tumors, and increasing age is the sole identifiable risk factor for orchiectomy. ,
Medial rotation that ranges from 360° to 720° in its own axis can cause interruption of the organ's vascularization as in present case (rotation of 720°). In addition, our patient had Type I attachment (only head and tail of epididymis attached to the testes). 
The most common signs and symptoms include red, swollen scrotum and acutely painful testicle, often in the absence of trauma, and the testis can lie horizontally with or without inflammatory signs. ,
However, in doubtful cases Doppler ultrasonography of the spermatic cord and testicular scintigraphy can be used to assess testicular perfusion. , When these tests are not promptly available, thus in doubtful cases following clinical examination, and when complementary exams cannot be performed, urgent scrotal exploration is the treatment of choice. No investigation substantially improves clinical diagnosis enough to warrant any delay in definitive surgical intervention. ,,,
Acute scrotal pain is most commonly caused by testicular torsion, torsion of the appendix testis, epididymitis and orchitis. Of these, only testicular torsion is an absolute surgical emergency as testicular salvage is inversely related to the duration of ischemia.  Physical examination techniques such as Prehn's sign (pain relieved when the testicle is elevated that occurs in orchitis) can be helpful in differentiating between epididymitis and testicular torsion.
Emergent imaging with Doppler ultrasound seems to be the most helpful in confirming the diagnosis though it is operator dependent and inaccurate results may be obtained in the prepubertal patient with small testicular volume. 
If the diagnosis is equivocal, radionuclide scan of the testicles (if possible) can be helpful to assess blood flow and to differentiate torsion from other conditions.
More recently, ultrasonography of the acute scrotum has gained acceptance, particularly in adults. Attractive aspects of sonography include its ready availability, its ability to obtain detailed anatomic information about the testis and scrotum, sensitivity of 99% and the avoidance of radiation. ,
Testicular torsion is a surgical emergency, and all efforts should be aimed at bringing the patient to the operating room as quickly as possible within the limits of surgical and anesthetic safety. Outcomes directly depend on the duration of ischemia; thus, time is of the essence. Time wasted attempting to arrange for imaging studies, laboratory testing, or other diagnostic procedures results in lost testicular tissue. ,
The goals of surgical exploration include (1) confirmation of the diagnosis of torsion, (2) detorsion of the involved testis, (3) assessment of the viability of the involved testis, (4) removal (if nonviable) or fixation (if viable) of the involved testis and (5) fixation of the contralateral testis, when appropriate. Because of the concern regarding the possibility of asynchronous testicular torsion, contralateral exploration and fixation is widely performed. ,,
The argument against surgical exploration includes the low probability of salvage in the setting of old torsion (>24-48 h). However, proponents of surgery argue that, in view of medicolegal implications, exploration needs to be performed to prove the diagnosis, to salvage the testis (if possible) and to concurrently perform a contralateral orchidopexy. ,
The clinician may attempt to manually reduce the torsion, but many need to be immediately referred to an urologist/surgeon for a surgical exploration and if successful (i.e. confirmed by color Doppler sonogram in a patient with complete resolution of symptoms),  definitive surgical fixation as an urgent procedure is still mandatory. The acutely painful scrotum is a common surgical emergency. ,
Common complications are testicular atrophy, torsion recurrence, wound infection and subfertility, , possibly related to ischemia - reperfusion injury that damages the blood - testis barrier, with resulting antisperm antibody production.
The primary objective of newer management is to avoid testicular loss. This requires a high index of clinical suspicion and prompt surgical intervention. If exploration is performed within 4-6 h of symptom onset, salvage rates may approach 90%; however, these rates dramatically drop to 50% at 12 h after symptom onset and to almost 10% after 24 h. In contrast, perinatal testicular torsion almost always results in loss of the involved testis (salvage rate <5%). 
The risk of testicular loss and reduced fertility are possible consequences of testicular torsion. 
Ongoing controversy surrounds the issue of exploration versus observation for testicular torsion. This condition is uncommon enough that few centers see enough cases to merit any prospective studies, and medicolegal issues likely drive much of the decision-making in this area. ,
Recurrent torsion following an orchidopexy is possible (although rare) and may occur several years after the initial fixation of the testis. Thus, patients and parents should be forewarned about this risk and should promptly seek medical care if testicular pain occurs, even after an orchidopexy has been performed.
Various experimental studies in animal models have investigated ways to minimize the testicular injury associated with ischemia and reperfusion injury. Agents as varied as superoxide dismutase, catalase, calcium channel blockers, oxypurinol and allopurinol have been used. Other agents recently used include melatonin  zinc aspartate  and dehydroepiandrosterone. 
Unfortunately, none of these models has yet generated adequate evidence to justify trials in human.
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