Testicular Torsion in a Teenager

Authors:
Lynnette Mazur, MD, MPH
Professor of Pediatrics at the McGovern Medical School, Houston Texas

Joel Matthews, BS
Second-year medical student at the University of Central Lancashire, UK

Bruce Sharp, BS
Fourth-year medical student at the McGovern Medical School, Houston, Texas

Citation:
Mazur L, Matthews J, Sharp B. Testicular torsion in a teenager [published online April 18, 2018]. Consultant for Pediatricians.

A mother called a pediatrics practice’s after-hours telephone service out of concern for her teenaged son’s sudden-onset right-sided groin pain. She reported that the boy’s pain had started earlier that day after school and had been steadily worsening. The pain now included the right testicle and was aggravated with crossing his legs. Nothing seemed to relieve the pain.

History. There was no history of fever, abdominal pain, dysuria, hematuria, nausea, vomiting, diarrhea, or trauma. He had experienced similar shorter episodes over the past few months but until now had not reported them to his parents. Out of suspicion for testicular torsion, the mother was instructed to take the boy to the emergency department (ED).

By the time he arrived at the ED, the pain had resolved. Scrotal Doppler ultrasonography was performed at the ED, the results of which showed a small right-sided hydrocele, with normal central arterial and venous flow in both testes.

He was discharged home and was seen by a pediatric urologist the following week. At that time, he was still asymptomatic, but the testicle had an abnormal horizontal lie (ie, a positive Brunzel sign) (Figure). To prevent future torsion, a bilateral orchidopexy was planned.

Figure. Horizontal lie of right testis (positive Brunzel sign)

Differential diagnosis. The differential diagnosis of scrotal pain is broad, but specific physical examination findings may aid in the diagnosis (Tables 1 and 2). Testicular torsion and intermittent testicular torsion (ITT) are closely related. Prompt differentiation and treatment is crucial to the survival of the testis.

Discussion. Testicular torsion is a suddenly occurring rotation of a testis about its axis. Twisting of the spermatic cord compromises venous drainage of the testis, reduces arterial perfusion, and results in testicular swelling and ischemia. ITT is defined as more than 1 attack of sudden unilateral scrotal pain of short duration (typically less than 2 hours) that resolves spontaneously.¹ Because almost 50% of patients with testicular torsion have had previous episodes of scrotal pain, and almost 10% of patients with ITT develop testicular torsion while awaiting surgery, ITT is considered a precursor of testicular torsion.^2,3

The incidence of testicular torsion is 1 in 4000 men per year, but because ITT resolves spontaneously, its prevalence is difficult to determine. Anatomically, torsion occurs because the testes and epididymis are abnormally fixed to the scrotum and are more mobile. This is also known as a bell-clapper deformity. Possible predisposing factors include rapid testicular growth during puberty, a suddenly occurring cremasteric reflex, exercise (particularly bicycling), and cold weather.⁴ There may also be a genetic predisposition; the genes encoding insulin-like 3 hormone (INSL3) and its receptor (RXFP2) have been investigated as candidates.⁵

The diagnosis of torsion is usually based on history and physical examination findings. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score helps determine a patient’s risk.⁶ Scoring includes testicular swelling (2 points), hard testis (2 points), absent cremasteric reflex (1 point), nausea/vomiting (1 point), and a high-riding testis (1 point).  Total TWIST scores of 0 points and 6 points have positive and negative predictive values of 93.5% and 100%, respectively.

When the diagnosis is questionable, ultrasonography is typically used to document testicular perfusion. However, both arterial and venous flow must be observed, because ITT may cause venous congestion with or without decreased arterial flow and can lead to testicular damage. Additionally, some experts do not recommend ultrasonography for the diagnosis of testicular torsion, because it delays surgical correction; up to 10% of cases have false-negative results.⁷ Treatment for both ITT and testicular torsion includes a bilateral orchidopexy. If testicular torsion is treated within the first 6 hours of symptoms, 90% of the affected testes remain viable. However, if it is untreated for more than 12 hours, almost 90% of testes are unsalvagable.^8,9

Conclusion. Our patient’s history, low TWIST score, and normal ultrasonography findings suggested ITT. Due to the risk of torsion and the possibility of segmental ischemia with chronic or recurrent ITT, orchidopexy was planned. However, a few days after his urology consult, the testis resumed a normal vertical lie, and surgery was cancelled. The patient and his parents were educated on the importance of timely evaluation and management should his symptoms recur. Although he had no recurrences over the next 18 months, an elective bilateral orchidopexy was performed in the summer before his third year of high school.

References:

1. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
2. Creagh TA, McDermott TE, McLean PA, Walsh A. Intermittent torsion of the testis. BMJ. 1988;297(6647):525-526.
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9. DaJusta DG, Granberg CF, Villanueva C, Baker LA. Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol. 2013;9(6 pt A):723-730.