Background: Testicular torsion is a urologic emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis can lead to loss of the testicle. In adolescent males, testicular torsion is the most frequent cause of testicle loss.
Pathophysiology: The typical testicle is covered by the tunica vaginalis, which attaches to the posterolateral surface of the testicle and allows for little mobility.
In patients who have an inappropriately high attachment of the tunica vaginalis (ie, bell clapper deformity), the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly is present in approximately 12% of males, 40% of which have the abnormality in the contralateral testicle as well. The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord, causing venous occlusion and engorgement, with subsequent arterial ischemia causing infarction of the testicle. Experimental evidence indicates that 720° torsion is required to compromise flow through the testicular artery and result in ischemia.
In the neonatal age group, the testicle frequently has not yet descended into the scrotum and becomes attached within the tunica vaginalis. Additionally, this mobility of the testicle predisposes it to torsion (extravaginal testicular torsion).
Frequency:
* In the US: Incidence of torsion in males younger than 25 years is approximately 1 in 4000.
Torsion more often involves the left testicle.
Mortality/Morbidity: This urologic emergency requires prompt diagnosis, immediate urologic referral, and rapid definitive treatment for salvage of the testicle.
* A salvage rate of 80-100% is found in patients who present within 6 hours of pain.
* After 6-8 hours, the salvage rate markedly decreases, and it is near 0% at 12 hours.
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