Testicular torsion
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Steven C. Campbell, M.D., Ph.D.
Synonyms and keywords: Torsion of the testis; testicular ischemia; testicular twisting
Overview
Steven C. Campbell, M.D., Ph.D.
Overview
In testicular torsion the spermatic cord that provides the blood supply to a testicle is twisted, cutting off the blood supply, often causing orchalgia. Prolonged testicular torsion will result in the death of the testicle and surrounding tissues.
It is also believed that torsion occurring during fetal development can lead to the so-called neonatal torsion or vanishing testis, and is one of the causes of an infant being born with monorchism.
Causes
Some men may be predisposed to testicular torsion as a result of inadequate connective tissue within the scrotum. However, the condition can result from trauma to the scrotum, particularly if significant swelling occurs. It may also occur after strenuous exercise or may not have an obvious cause.
Epidemiology and Demographics
While torsion is more frequent among adolescents, it should be considered in all cases where there is testicular pain. Torsion occurs more frequently in patients who do not have evidence of inflammation or infection.
Diagnosis
Laboratory Findings
Urinalysis (analyzing chemical composition of urine) can be used to rule out bacterial infections.
Treatment
Primary Prevention
Use precautions to avoid trauma to the scrotum. Many cases are not preventable.
References
Historical Perspective
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References
Pathophysiology
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References
Differentiating Testicular Torsion from other Diseases
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]
Overview
Testicular torsion should be differentiated from other conditions presenting with lower abdominal pain, nausea and vomiting.
Differentiating Testicular Torsion From Other Diseases
Testicular torsion should be differentiated from other conditions presenting with lower abdominal pain , nausea and vomiting. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]
| Category | Disease | History | Signs and Symptoms | Physical Examination | Laboratory abnormalities | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nausea/vomiting | Hematuria | Location of pain | Fever | Tachycardia | Hypotension | Hypertension | Anorexia | Constipation | Rebound abdominal tenderness | Urinary frequency/Urgency/Dysuria | Costovetebral angle tenderness | Pelvic Examination | Rectal Examination | Complete Blood Count (CBC) | Urinalysis | BUN | Creatinine | Stone analysis | Urine Beta- hCG | Abnormal Liver Function Tests (LFTs) | Serum Amylase/Lipase | Abdominal/Pelvic CT scan | Serum Parathyroid hormone levels (PTH) | |||
Renal Pathology |
Nephrolithiasis |
|
+ | + | – | + | – | – | +/- | – | – | + | – | – | – | – | – | – | – |
|
+/- | |||||
| Pyelonephritis |
|
+ | + (microscopic) |
|
+ | + | + | – | +/- | – | + | + | + | – |
|
– | – | – | – |
|
– | |||||
| Renal infarct | + | + | + | + | – | + | – | – | – | – | – | – | – | – | – | – | ||||||||||
| Renal papillary necrosis | – | + (microscopic) | + | +/- | – | + | – | – | – | + | – | – | – | – | – | – | – |
|
– | |||||||
| Renal cell carcinoma |
|
+ | + (microscopic) | – | – | – | + | + | +/- | – | – | – | – | – |
|
|
– | – | – | – |
|
– | ||||
| Uretral stricture |
|
– | +/- | – | – | – | – | – | – | – | – | + | – | – | – | – | – | – | – | – | – | – | – | |||
Prostate Pathology |
Prostatitis |
|
– | + |
|
+ | + | – | – | – | – | – | + | – | – |
|
– | – | – | – | – | – | – | |||
| Prostatic cancer |
|
– | + | – | – | – | – | – | + | – | – | + | – | – |
|
– |
|
– | – | – | – |
|
– | |||
Testicular Pathology |
Testicular torsion |
|
+ | – |
|
– | + | – | – | +/- | – | – | +/- | – |
|
– | – | – | – | – | – | – | – | – |
|
– |
| Orchitis |
|
+ | – |
|
+ | + | – | – | – | – | – | +/- | – |
|
– | – | – | – | – | – | – | – |
|
– | ||
Abdominal Pathology |
Cholecystitis |
|
+ | – | + | + | – | – | + | – | – | – | – | – | – | – | – | – |
|
– | + | +/- |
|
– | ||
| Appendicitis |
|
+ | – |
|
+ | + | – | – | + | – | + | +/- | – | – | – |
|
– | – | – | – | – | – | + (if perforation) |
|
– | |
| Diverticulitis |
|
+ | – | + | + | – | – | + | + | – | – | – | – | – | – | – | – | – | – | + (if perforation) |
|
– | ||||
| Abdominal aortic aneurysm | – | – |
|
– | + | + | – | – | – | + (if rupture) | – | – | – | – | – | – | – | – | – | – | – | – |
|
– | ||
| Portal vein thrombosis | + | – | + | + | + | – | + | – | + (if bowel ischemia or infarction-secondary to extension of thrombus to superior mesenteric vein) | – | – | – | – | – | – | – | – | + | + (if bowel infarction, perforation) |
|
||||||
| Duodenal ulcer |
|
+ | – | + | + | + | – | – | – | + (if perforation) | – | – | – | – | – | – | – | + (if bowel perforation) | – | |||||||
| Ischemic colitis |
|
+ | – |
|
+ | + | + (if necrosis and sepsis) | + | + | + | + (if transmural necrosis) | – | – | – |
|
– | – | – | – | + (if bowel perforation) |
|
– | ||||
References
- ↑ Worcester EM, Coe FL (June 2008). “Nephrolithiasis”. Prim. Care. 35 (2): 369–91, vii. doi:10.1016/j.pop.2008.01.005. PMC 2518455. PMID 18486720.
- ↑ Semins MJ, Matlaga BR (February 2010). “Medical evaluation and management of urolithiasis”. Ther Adv Urol. 2 (1): 3–9. doi:10.1177/1756287210369121. PMC 3126068. PMID 21789078.
- ↑ Venkatesh L, Hanumegowda RK (June 2017). “Acute Pyelonephritis – Correlation of Clinical Parameter with Radiological Imaging Abnormalities”. J Clin Diagn Res. 11 (6): TC15–TC18. doi:10.7860/JCDR/2017/27247.10033. PMC 5535453. PMID 28764263.
- ↑ Garin EH, Olavarria F, Araya C, Broussain M, Barrera C, Young L (July 2007). “Diagnostic significance of clinical and laboratory findings to localize site of urinary infection”. Pediatr. Nephrol. 22 (7): 1002–6. doi:10.1007/s00467-007-0465-7. PMID 17375337.
- ↑ Lee DG, Jeon SH, Lee CH, Lee SJ, Kim JI, Chang SG (April 2009). “Acute pyelonephritis: clinical characteristics and the role of the surgical treatment”. J. Korean Med. Sci. 24 (2): 296–301. doi:10.3346/jkms.2009.24.2.296. PMC 2672131. PMID 19399273.
- ↑ Saeed K (2012). “Renal infarction”. Int J Nephrol Renovasc Dis. 5: 119–23. doi:10.2147/IJNRD.S33768. PMC 3437809. PMID 22969301.
- ↑ Mahamid M, Francis A, Abid A, Awawde M, Abu-Elhija O (2014). “Embolic renal infarction mimicking renal colic”. Int J Nephrol Renovasc Dis. 7: 157–9. doi:10.2147/IJNRD.S59745. PMC 4011809. PMID 24812524.
- ↑ Korzets Z, Plotkin E, Bernheim J, Zissin R (October 2002). “The clinical spectrum of acute renal infarction”. Isr. Med. Assoc. J. 4 (10): 781–4. PMID 12389340.
- ↑ Brix AE (2002). “Renal papillary necrosis”. Toxicol Pathol. 30 (6): 672–4. doi:10.1080/01926230290166760. PMID 12512867.
- ↑ Eknoyan G, Qunibi WY, Grissom RT, Tuma SN, Ayus JC (March 1982). “Renal papillary necrosis: an update”. Medicine (Baltimore). 61 (2): 55–73. PMID 7038374.
- ↑ Ng CS, Wood CG, Silverman PM, Tannir NM, Tamboli P, Sandler CM (October 2008). “Renal cell carcinoma: diagnosis, staging, and surveillance”. AJR Am J Roentgenol. 191 (4): 1220–32. doi:10.2214/AJR.07.3568. PMID 18806169.
- ↑ Ares Valdés Y, Amador Sandoval B, Morales JC, Alonso Domínguez F, Carballo Velásquez L, Fragas Valdés R, Shou Rodríguez A (September 2004). “[The role of CT scan in the diagnosis of renal cell carcinoma]”. Arch. Esp. Urol. (in Spanish; Castilian). 57 (7): 737–42. PMID 15536955.
- ↑ Leveridge MJ, Bostrom PJ, Koulouris G, Finelli A, Lawrentschuk N (June 2010). “Imaging renal cell carcinoma with ultrasonography, CT and MRI”. Nat Rev Urol. 7 (6): 311–25. doi:10.1038/nrurol.2010.63. PMID 20479778.
- ↑ Tritschler S, Roosen A, Füllhase C, Stief CG, Rübben H (March 2013). “Urethral stricture: etiology, investigation and treatments”. Dtsch Arztebl Int. 110 (13): 220–6. doi:10.3238/arztebl.2013.0220. PMC 3627163. PMID 23596502.
- ↑ Mundy AR, Andrich DE (January 2011). “Urethral strictures”. BJU Int. 107 (1): 6–26. doi:10.1111/j.1464-410X.2010.09800.x. PMID 21176068.
- ↑ Maciejewski C, Rourke K (February 2015). “Imaging of urethral stricture disease”. Transl Androl Urol. 4 (1): 2–9. doi:10.3978/j.issn.2223-4683.2015.02.03. PMC 4708283. PMID 26816803.
- ↑ Soper DE (August 2010). “Pelvic inflammatory disease”. Obstet Gynecol. 116 (2 Pt 1): 419–28. doi:10.1097/AOG.0b013e3181e92c54. PMID 20664404.
- ↑ Paavonen J (October 1998). “Pelvic inflammatory disease. From diagnosis to prevention”. Dermatol Clin. 16 (4): 747–56, xii. PMID 9891675.
- ↑ Lee MH, Moon MH, Sung CK, Woo H, Oh S (December 2014). “CT findings of acute pelvic inflammatory disease”. Abdom Imaging. 39 (6): 1350–5. doi:10.1007/s00261-014-0158-1. PMID 24802548.
- ↑ Eggert J, Sundquist K, van Vuuren C, Fianu-Jonasson A (October 2006). “The clinical diagnosis of pelvic inflammatory disease–reuse of electronic medical record data from 189 patients visiting a Swedish university hospital emergency department”. BMC Womens Health. 6: 16. doi:10.1186/1472-6874-6-16. PMC 1624808. PMID 17054801.
- ↑ Washington C, Carmichael JC (December 2012). “Management of ischemic colitis”. Clin Colon Rectal Surg. 25 (4): 228–35. doi:10.1055/s-0032-1329534. PMC 3577613. PMID 24294125.
- ↑ Chawla YK, Bodh V (March 2015). “Portal vein thrombosis”. J Clin Exp Hepatol. 5 (1): 22–40. doi:10.1016/j.jceh.2014.12.008. PMC 4415192. PMID 25941431.
- ↑ “Imaging of Abdominal Aortic Aneurysms – – American Family Physician”.
- ↑ Aggarwal S, Qamar A, Sharma V, Sharma A (2011). “Abdominal aortic aneurysm: A comprehensive review”. Exp Clin Cardiol. 16 (1): 11–5. PMC 3076160. PMID 21523201.
- ↑ Destigter KK, Keating DP (August 2009). “Imaging update: acute colonic diverticulitis”. Clin Colon Rectal Surg. 22 (3): 147–55. doi:10.1055/s-0029-1236158. PMC 2780264. PMID 20676257.
- ↑ Hameed AM, Lam VW, Pleass HC (February 2015). “Significant elevations of serum lipase not caused by pancreatitis: a systematic review”. HPB (Oxford). 17 (2): 99–112. doi:10.1111/hpb.12277. PMC 4299384. PMID 24888393.
- ↑ “Imaging for Suspected Appendicitis – – American Family Physician”.
- ↑ “CT Findings of Acute Cholecystitis and Its Complications : American Journal of Roentgenology : Vol. 194, No. 6 (AJR)”.
- ↑ “Epididymitis and Orchitis: An Overview – – American Family Physician”.
- ↑ Jia JB, Houshyar R, Verma S, Uchio E, Lall C (January 2016). “Prostate cancer on computed tomography: A direct comparison with multi-parametric magnetic resonance imaging and tissue pathology”. Eur J Radiol. 85 (1): 261–267. doi:10.1016/j.ejrad.2015.10.013. PMID 26526901.
- ↑ Bratt O, Lilja H (January 2015). “Serum markers in prostate cancer detection”. Curr Opin Urol. 25 (1): 59–64. doi:10.1097/MOU.0000000000000128. PMC 4315142. PMID 25393274.
- ↑ “Prostate Cancer (Prostate Carcinoma): Symptoms – National Library of Medicine – PubMed Health”.
- ↑ Eskicioğlu F, Özdemir AT, Turan GA, Gür EB, Kasap E, Genç M (November 2014). “The efficacy of complete blood count parameters in the diagnosis of tubal ectopic pregnancy”. Ginekol. Pol. 85 (11): 823–7. PMID 25675798.
- ↑ Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW (October 2011). “Diagnosis and management of ectopic pregnancy”. J Fam Plann Reprod Health Care. 37 (4): 231–40. doi:10.1136/jfprhc-2011-0073. PMC 3213855. PMID 21727242.
Epidemiology and Demographics
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Steven C. Campbell, M.D., Ph.D.
Overview
While torsion is more frequent among adolescents, it should be considered in all cases where there is testicular pain. Torsion occurs more frequently in patients who do not have evidence of inflammation or infection.
References
Risk Factors
Steven C. Campbell, M.D., Ph.D.
Risk Factors
In most males, the testicles are attached to the inner lining of the scrotum. Males whose attachment is higher up are at risk of testicular torsion. This condition is known as a bell clapper deformity (as in the central piece of a bell) and is a major cause of testicular torsion. A male who notices the ability of either or both testicles to freely rotate within the scrotum should be aware that he is at risk of testicular torsion. Testicles that are in a much lower position and/or in a slightly rotated position in the scrotal sack are a visual indicator of this risk.
Torsions are sometimes called “winter syndrome”. This is because they often happen in winter, when it is cold outside. The scrotum of a man who has been lying in a warm bed is relaxed. When he arises, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.
References
Natural History, Complications and Prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Complications
If the blood supply is cut off to the testicle for a prolonged period of time, it may atrophy (shrink) and need to be surgically removed. Atrophy of the testicle may occur days-to-months after the torsion has been corrected. Severe infection of the testicle and scrotum is also possible if the blood flow is restricted for a prolonged period.
Prognosis
If the condition is diagnosed quickly and immediately corrected, the testicle may continue to function properly. After 6 hours of torsion (impaired blood flow), the likelihood that the testicle will need to be removed increases. However, even with less than 6 hours of torsion, the testicle may lose its ability to function.
References
Diagnosis
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | Ultrasound | Other Diagnostic Studies
Treatment
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
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