Torsion of testicles

Testicular torsion is a pathological twisting of the spermatic cord caused by the rotation of the mezorchium (folds between the testicle and its appendage), which leads to the impairment or necrosis of testicular tissue.

Epidemiology

Testicular torsion occurs with a frequency of 1 in 500 patients in urological clinics.

In the first 10 years of life, testicular torsion is noted in 20% of cases, and after 10 years and before puberty - in 50%. Thus, the main place in the etiopathogenesis of acute testicular diseases in children is occupied by mechanical factors, such as testicular torsion.

[1], [2], [3], [4], [5], [6]

Causes of the torsion of testicle

The provoking factor of torsion of the testicles can be injuries and bruises of the scrotum, sudden movements, tension of the abdominals, which leads to a reflex contraction of the muscles that lift the testicle. The lack of a normal attachment of the testicle to the bottom of the scrotum - an anomaly that occurs during the period of attachment of the appendage to the testicle - leads to a violation of mutual fixation, which entails the separation of these two entities. The testicle is subject to twisting in case of malformations associated with the violation of its migration into the scrotum (cryptorchism).

[7], [8], [9]

Pathogenesis

The testicle rotates around the vertical axis. If the rotation of the testicles together with the spermatic cord exceeds 180 °, the blood circulation is disturbed in the testicle, numerous hemorrhages are formed, a venous thrombosis of the spermatic cord occurs, a serous-hemorrhagic transudate occurs in the cavity of the testicular's own membrane; the skin of the scrotum becomes edematous.

Extravaginal, or suprashell, testicular torsion occurs along with its membranes. The testicle in relation to the vaginal process of the peritoneum is located mesoperitoneally and its fixation is not broken. The crucial role in the development of this form of testicular torsion is not played by its developmental defect, but by the morphological immaturity of the spermatic cord and surrounding tissues - hypertonicity of the muscle that lifts the testicle, the friability of the adhesions of the membranes between them, a short wide inguinal canal having an almost straight direction.

Intravaginal, or intrathecal, testicular torsion (intravaginal form) occurs in the cavity of its own vaginal membrane. It is observed in children over the age of 3 years, especially at the age of 10-16 years. Torsion of the testicle occurs as follows. With the contraction of the muscle that raises the testicle, it, together with the surrounding shells, pulls up and makes a rotational movement. The rigidity and density of adhesions of the membranes, as well as the inguinal canal, intimately covering the spermatic cord in the form of a tube (in older children), do not allow the testicle to make a full rotation around the axis, so at some point the rotation stops.

The testicle, which has a long mesentery and, as a result, has a high mobility inside the cavity of the vaginal process of the peritoneum, continues to rotate by inertia. Then the muscle fibers relax. The testicle, raised to the upper section of the scrotum cavity, is fixed and held in its convex parts in a horizontal position. With further contraction of the muscle that raises the testicle, the inversion continues. The longer the mesentery and the greater the force of contraction of the muscles that raise the testicle, and the greater the mass of the testicle, the more pronounced the degree of torsion.

The authors explain the increase in the frequency of intranaginal twists during the prepubertal and pubertal periods by a disproportionate increase in the mass of the testicle at this age. This indicates that the mechanism of intravaginal torsion of the testicle, along with other factors, plays a certain role in the imbalance of the reproductive apparatus.

[10], [11], [12]

Symptoms of the torsion of testicle

Torsion of testicle symptoms is acute. They are manifested by sharp pains in the testicle, in the corresponding half of the scrotum, radiating to the groin area; sometimes accompanied by nausea, vomiting, and a collaptoid state.

The symptoms of testicular torsion depend on the duration of the disease and the age of the child. In newborns, testicular torsion is most often found during the initial physical examination as a painless increase in half of the scrotum. Often, hyperemia or blanching of the skin of the scrotum, as well as hydrocele, is noted. Infants are restless, shouting, refuse to breast. Older children complain of testicular torsion symptoms such as:  pain in the lower abdomen  and in the groin area. At the external inguinal ring or the upper third of the scrotum appears painful tumor-like formation. In the future, the twisted testicle is raised and when you try to raise it even higher, the pain increases (Pren's symptom).

[13], [14]

Complications of testicular torsion and its hydatid

The problem of prevention, timely diagnosis and treatment of acute diseases of the scrotum organs is of great importance. First, 77-87.3% of the cases are people of working age from 20 to 40 years; secondly, in 40-80% of patients who have experienced acute diseases of the scrotum organs, atrophy of the spermatogenic epithelium occurs and, as a result,  infertility. Conservative treatment of testicular torsion ends with a testicle atrophy, and later operative either with the removal of the testicle or epididymis or with its atrophy.

Causes of  atrophy of the testicles  after suffering epilepsy:

• direct damaging effect of the etiological factor on the parenchyma;
• violation of the blood testis barrier with the development of autoimmune aggression;
• development of ischemic necrosis.

Clinical and morphological studies have revealed that in all forms of acute diseases of the scrotum organs, in many respects identical processes occur. Manifesting characteristic clinical picture and neurodystrophic tissue changes. Acute diseases of the scrotum cause mainly identical violations of spermatogenesis, expressed in prospermia, violation of the content of the microelement composition of the ejaculate, reducing the area of the nucleus and sperm head, reducing the content of DNA in them.

Ischemic necrosis in this case is the result of edema of the parenchyma, its albumin. All this justifies the tendency in recent years to early surgical treatment of acute diseases of the scrotum organs, since it allows you to quickly eliminate ischemia, detect the disease in time, thereby retaining the functional ability of the testicle. Early surgical treatment is indicated for severe pain, development of reactive dropsy of the testicle, purulent inflammation and suspected rupture of the scrotum organs, twisting of the testicles, hydatiditis and its appendage.

[15], [16], [17], [18], [19]

Forms

There are two forms of testicular torsion.

• Extravaginal testicular torsion (above the parietal attachment of the leaflet of the vaginal process of the peritoneum) is observed in children under 1 year of age;
• Intravaginal testicular torsion - occurs more often in children than in adults.

[20], [21]

Diagnostics of the torsion of testicle

It is necessary to carefully collect the history of the disease. Factors such as recent trauma to the scrotum, dysuria, hematuria, discharge from the urethra, sexual activity and the time elapsed since the onset of clinical manifestations should be noted.

[22], [23], [24], [25]

Clinical diagnosis of testicular torsion

It is necessary to examine the abdominal cavity, genitals and perform  rectal examination. Particular attention should be paid to the presence or absence of discharge from the urethra, the position of the affected testicle and its axis, the presence or absence of a hydrocele on the opposite side, the presence of induration or excess tissue in the testicle or its appendage, the change in color of the scrotum.

The testicles are usually palpated at the upper edge of the scrotum, which is associated with shortening of the spermatic cord. Palpation of the scrotum slightly painful. Sometimes when torsion the appendage is located in front of the testicle. Seminal cord due to torsion thickened. Subsequently, swelling and hyperemia of the scrotum is observed. Due to impaired lymph drainage, there is a secondary hydrocele.

[26],

Laboratory diagnosis of testicular torsion

To exclude infection, it is necessary to do a urine test.

[27], [28], [29]

Instrumental diagnosis of testicular torsion

With  Doppler ultrasound, the  architectonics of the testicle and its appendage are clearly visible, an experienced doctor can obtain evidence of the presence or absence of blood flow in the testicle.

Echographically, testicular torsion is characterized by the inhomogeneity of the parenchymal image with irregular alternation of hyper- and hyposhogenic areas, thickening of the integuinal tissues of the scrotum, edematous hyper-echogenic appendage, and a small amount of hydrocele. At an early stage, changes in the gray scale mode may not be detected by the echography or they are not specific (change in echo density). Later, a change in structure (heart attack and bleeding) is recorded. Comparative studies have shown that a testicle with unchanged echo density during an operation appears to be viable, and testicles that are hypoechogenic or heterogeneous in echogenicity are not viable.

All other echographic signs (size, blood supply and thickness of the scrotum skin, the presence of a reactive hydrocele) are prognostic insignificant. The use of tissue (energy) Doppler mapping is necessary. The study should be carried out symmetrically to identify minimal changes, such as, for example, with incomplete torsion or spontaneous resolution. In the affected organ, the blood flow is depleted and is not even completely detected (with inflammation, the blood flow increases). Spontaneous elimination of torsion leads to a reactive increase in blood flow, clearly visible compared with previous studies.

In order to determine the nature of the contents of the membranes (blood, exudate) perform diaphanoscopy and diagnostic puncture.

[30]

Differential diagnosis

Differential diagnosis of testicular torsion is carried out with  orchitis  (inflammation of the testicle), complicating infectious parotitis, and allergic angioedema. In the latter, as a rule, the entire scrotum is enlarged, the liquid permeates all its layers, forming a water bubble under the thinned skin.

[31], [32], [33], [34], [35], [36], [37],

Treatment of the torsion of testicle

Non-drug treatment of testicular torsion

In 2-3% of patients, torsion can be eliminated in the first hours of the disease. By carrying out outdoor manual detortion.

[38], [39]

External manual detortion of the testicle

The patient is placed on his back detorsy perform in the direction opposite to the inversion of the testicle. It should be remembered that the right testicle is rotated clockwise, the left one against. A convenient guide when choosing the direction of unwinding of the testicle is the midline suture of the scrotum. The testicle with scrotal tissue is gripped and rotated 180 ° in the direction opposite to the midline suture of the scrotum skin. At the same time produce a light traction down the testicle. After that, it is lowered and the manipulation is repeated several times.

With successful detortion, testicular pain disappears or significantly decreases. It becomes more mobile, occupies the usual position in the scrotum. In case of ineffectiveness of the conservative detoria within 1-2 minutes, the manipulation is stopped and the patient is operated on. The earlier the detortion is performed and the older the child, the better the result of the operation.

[40], [41], [42], [43], [44]

Surgical treatment of testicular torsion

If the ultrasound can not be performed or the results of its application are uncertain, then surgical intervention is indicated.

With edematous scrotum syndrome, urgent surgery is necessary, because the testicle is very sensitive to ischemia and can quickly die (irreversible changes occur after 6 hours).

The choice of access depends on the shape of the turn and the age of the child. In newborns and infants, inguinal access is used, since they have an extravaginal torsion form. In older children and in adults, the intravaginal form prevails, therefore access via the scrotum is more convenient.

[45], [46], [47]

Technique for torsion of the testicles

In all cases, the testicle is exposed to the albuginea, which allows for a wide resection, and the shape of the inversion is determined. The testicle is dislocated into the wound, produces detortion and assesses its viability. To improve the microcirculation and determine the preservation of the testicle, it is recommended to inject into the region of the spermatic cord 10-20 ml of a 0.25-0.5% solution of procaine (novocaine) with sodium heparin. If blood circulation does not improve within 15 minutes after this, an orchiectomy is indicated. To improve blood circulation, heat compresses with isotonic sodium chloride solution are used for 20-30 minutes. When blood circulation is restored, the testicle acquires a normal color.

The testicle is removed only with its complete necrosis. If it is difficult to resolve the question of the viability of the affected testicle. I WOULD. Yudin. A.F. Sakhovsky recommend using transillumination testicle test on the operating table. Translucence of the testicle indicates its viability. In the absence of a translucency symptom, the authors recommend making an incision in the testicles of the testicle at the lower pole; bleeding from the vessels of this membrane indicates the viability of the body.

Necrotized testicle, despite measures to improve its vascularization, does not change color. The pulsation of vessels below the strangulation site is absent, the vessels of the tunica albug do not bleed. The stored testicle is stitched with two or three sutures to the scrotum septum by the lower ligament of the appendage without tensioning the elements of the spermatic cord.

A drainage tube is inserted into the wound as in acute epilensis and a permanent irrigation with antibiotics is established for 2-3 days, depending on the severity of the destructive changes and the inflammatory process.

In the case of testicular torsion with cryptorchidism after detortion, the above measures are carried out. The atrophied testicle is removed, the viable testicle is reduced to the scrotum and fixed.

Further management

In the postoperative period, patients are prescribed sensitizers, physiotherapy, drugs that normalize microcirculation in the damaged organ (daily Novocain blockade of the spermatic cord, intramuscular administration of sodium heparin, reopolyglucin, etc.). To reduce the permeability of the blood-testing barrier in the postoperative period, patients are prescribed acetylsalicylic acid (0.3–1.5 g per day) for 6–7 days.

If necessary, in the following practice, preventive orchidopexy from the opposite side can be used to prevent testicular torsion in the future.

It is proved that while the dead testicle is preserved in the long-term period of the disease, sperm antibodies appear in the patient's body, testicular torsion extends to the contralateral testicle, which ultimately leads to infertility.

[48], [49], [50]