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Testicular Torsion

Testicular Torsion is a topic covered in the 5-Minute Clinical Consult.

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5-Minute Clinical Consult

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Basics

Description

  • 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

Geriatric Considerations
Rare in this age group

Pediatric Considerations
Peak incidence at age 14 years

Epidemiology

Incidence
  • ~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.

Genetics
  • Unknown
  • Familial testicular torsion, although previously rarely reported, may involve as many as 10% of patients.

Risk Factors

  • May be more common in winter
  • Paraplegia
  • Previous contralateral testicular torsion

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Citation

Stephens, Mark B., et al., editors. "Testicular Torsion." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. 5minute, www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116592/all/Testicular_Torsion.
Testicular Torsion. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116592/all/Testicular_Torsion. Accessed March 22, 2019.
Testicular Torsion. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116592/all/Testicular_Torsion
Testicular Torsion [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 22]. Available from: https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116592/all/Testicular_Torsion.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Testicular Torsion ID - 116592 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116592/all/Testicular_Torsion PB - Wolters Kluwer ET - 27 DB - 5minute DP - Unbound Medicine ER -