Testicular torsion is a surgical emergency, and clinicians caring for adolescent males must have a high index of suspicion given the short window for salvage of the testicle.
The exact etiology of torsion is unknown. However, the most common testicular anatomical abnormality, called the “bell clapper” deformity, can predispose to testicular torsion (Fig. 78-1). In this deformity, the tunica vaginalis completely surrounds the testicle, including the posterior aspect, and the absence of the normal posterior anchoring at the gubernaculum testis allows the testicle to twist freely.
CLINICAL MANIFESTATIONS AND DIAGNOSIS
Common presentation includes abrupt onset of severe scrotal pain with associated nausea, vomiting, fever, and abdominal pain. Symptomatic males may describe prior transient episodes of scrotal pain consistent with intermittent torsion/detorsion. Typically, the adolescent presents later in the course with a scrotum that is swollen, tender, erythematous, and often difficult to examine. The cremasteric reflex is nearly always absent. Prehn’s sign (ie, lessening of pain with scrotal elevation) had been used in the past to differentiate torsion from epididymitis, but it has since been found to be inferior to ultrasound. Diagnosis can be made on physical examination or with the assistance of color Doppler ultrasound, which has a sensitivity of 100% and a specificity of 75% (Fig. 78-2).
Abnormal testicular ultrasound.
Treatment involves prompt surgical exploration and detorsion. Time is of the essence because testicular viability declines to 0 after 24 hours. Given the high incidence of retorsion, as well as torsion of the contralateral testis, the affected testis and the contralateral testis are fixed to the scrotum in a procedure called scrotal orchiopexy.
TORSION OF TESTICULAR OR EPIDIDYMAL APPENDAGE
Both the testis and the epididymis have appendages (Fig. 78-3) that are remnants of the wolffian and müllerian ducts, respectively. The pedunculated shape of the appendages predisposes them to torsion.
Testicular and epididymal appendage.
The typical presentation of appendiceal torsion occurs in boys ages 7 to 12 years and includes pain that may be accompanied by nausea and vomiting. Palpation of the testis reveals tenderness over the superior or inferior pole of the testes with or without a palpable mass. The cremasteric reflex is usually present. The classic “blue dot” sign, if present, represents the infarcted appendage viewed through the scrotal skin.