Torsion of the testis is an emergency requiring prompt diagnosis and treatment to save the affected testis. Torsion accounts for 40% of cases of acute scrotal pain and swelling and is the major cause of the acute scrotum in boys less than 6 years of age. It is thought to arise from abnormal fixation of the testis to the scrotum. On examination the testicle is swollen and tender, and the cremasteric reflex is absent. The absence of blood flow on nuclear scan or Doppler ultrasound is consistent with torsion.
The differential diagnosis of testicular pain includes trauma, an incarcerated hernia, and torsion of the testicular epididymal appendix. Torsion of the appendix testis is associated with point tenderness over the lesion and minimal swelling. In adolescents, the differential diagnosis of testicular torsion also must include epididymitis, the most common cause of acute scrotal pain and swelling in older adolescents. Diagnosis is aided by an antecedent history of sexual activity or UTI. Testicular torsion must be considered as the principal diagnosis when severe acute testicular pain is present.
The undescended testis is usually histologically normal at birth. Atrophy and dysplasia are found after the first year of life. Some boys have congenital dysplasia in the contralateral descended testis. Surgical correction at an early age results in greater chance of adult fertility. Administration of human chorionic gonadotropin causes testosterone release from functioning testes and may result in descent of retractile testes.
Orchidopexy is usually done in the second year of life. Most extra-abdominal testes can be brought into the scrotum with correction of the associated hernia. If the testis is not palpable, ultrasound or magnetic resonance imaging may determine its location. The closer the testis is to the internal inguinal ring, the better the chance of successful orchidopexy.
Surgical correction of testicular torsion is called detorsion and fixation of the testis. If performed within 6 hours of torsion, there is greater than a 90% chance of testicular salvage. The contralateral testis usually is fixed to the scrotum to prevent possible torsion. If torsion of the appendix is found, the necrotic tissue is removed.
We gratefully acknowledge the invaluable contributions of Rama Jayanthi, MD, Pediatric Urology, Nationwide Children’s Hospital, Columbus, Ohio.
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