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- Twisting of testis and spermatic cord, resulting in acute ischemia and loss of testis if unrecognized:
- Intravaginal torsion: occurs within tunica vaginalis, only involves testis and spermatic cord
- Extravaginal torsion: involves twisting of testis, cord, and processus vaginalis as a unit; typically seen in neonates
- System(s) affected: reproductive
Rare in this age group
Peak incidence at age 14 years
- ~1/4,000 males before age 25 years
- Predominant age:
- Occurs from newborn period to 7th decade
- 65% of cases occur in 2nd decade, with peak at age 14 years.
- Second peak in neonates (in utero torsion usually occurs around week 32 of gestation)
Etiology and Pathophysiology
- Twisting of spermatic cord causes venous obstruction, edema of testis, and arterial occlusion.
- “Bell clapper” deformity is most common anatomic anomaly predisposing to intravaginal torsion:
- High insertion of the tunica vaginalis on the spermatic cord, resulting in increased testicular mobility within tunica vaginalis
- Bilateral in ~80% of patients
- No clear anatomic defect is associated with extravaginal testicular torsion:
- In neonates, the tunica vaginalis is not yet well attached to scrotal wall, allowing torsion of entire testis including tunica vaginalis.
- Usually spontaneous and idiopathic
- 20% of patients have a history of trauma.
- 1/3 have had prior episodic testicular pain.
- Contraction of cremasteric muscle or dartos may play a role and is stimulated by trauma, exercise, cold, and sexual stimulation.
- Increased incidence may be due to increasing weight and size of testis during pubertal development.
- Possible alterations in testosterone levels during nocturnal sex response cycle; possible elevated testosterone levels in neonates
- Testis must have inadequate, incomplete, or absent fixation within scrotum.
- Torsion may occur in either clockwise or counterclockwise direction.
- Familial testicular torsion, although previously rarely reported, may involve as many as 10% of patients.
- May be more common in winter
- Previous contralateral testicular torsion