|Year : 2012 | Volume
| Issue : 2 | Page : 182-184
Testicular torsion: Needless testicular loss can be prevented
Gabriel E Njeze
Department of Surgery, Enugu State University of Technology Teaching Hospital Park Lane, Enugu, Nigeria
|Date of Acceptance||06-Dec-2011|
|Date of Web Publication||16-Jun-2012|
Gabriel E Njeze
Department of Surgery, Enugu State University of Technology Teaching Hospital Park Lane, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The risk of losing the testis is an ever present threat in patients with testicular torsion, who delay before presenting to the surgeon. A retrospective study was carried out to audit patients with acute scrotal pain who came to the Trans Ekulu Hospital Enugu, the promptness of offering them surgical treatment and the results.
Materials and Methods: Patients operated upon for suspected torsion of the testis at Trans Ekulu Hospital Enugu over a 10-year period (1993-2003) were studied. The intervals between the onset of scrotal pain and presentation at the hospital were recorded. The duration of scrotal pain, findings on examination of the scrotum, time of starting surgical operation, and the number of viable testes seen intraoperatively were documented.
Results: Twenty-two patients were found to have undergone emergency scrotal exploration and their ages ranged from 10 to 38 years with a mean of 22.7 years. Eight of these patients came within 3 hours of onset of scrotal pain, one patient came within the 6 hours, and the rest came late. These patients were operated upon shortly after arrival at the hospital.
Sixteen patients (72.7%) had testicular torsion, 12 testes were viable, and 4 nonviable.
Conclusion: Majority of our patients presented reasonably early. Those who had testicular loss came late. However, some who came late still had viable testes.
Keywords: Health education, orchidectomy, orchidopexy, testicular loss, torsion
|How to cite this article:|
Njeze GE. Testicular torsion: Needless testicular loss can be prevented. Niger J Clin Pract 2012;15:182-4
| Introduction|| |
Testicular torsion leading to orchidectomy is a major catastrophe for the patient and continues to occur.  It is characterized by excruciating one-sided testicular or scrotal pain, followed by swelling, and emergency surgical treatment is required for this condition. Each year, 1 in 4000 men younger than 25 years suffers testicular torsion.  The cause of the majority of cases is the bell clapper deformity, an anatomic abnormality that is present in around 12% of males,  but trauma  and increase in testicular volume  can cause torsion. Early diagnosis and definitive surgical treatment are the keys to avoid testicular loss. All prepubertal and young adult males with acute scrotal pain should be considered to have testicular torsion until proven otherwise.  Epididymitis/orchitis is much less common in young males, and the diagnosis should be made with caution in this group.
Even though these facts have been known for a very long time, surgical literature is replete with reports of delayed presentation, misdiagnosis, and wrong treatment leading to testicular wastage. , In view of these continuing reports about late presentation and consequent orchidectomy for testicular infarction, a decision was made to audit the presentation, clinical assessment, and outcome of treatment of patients with suspected testicular torsion treated at the Trans Ekulu Hospital Enugu. The aim of this audit was to use the findings to contribute to efforts aimed at reducing the incidence of testicular loss from torsion.
| Materials and Methods|| |
Every patient who had exploration of the scrotum for suspected torsion of the testis at Trans Ekulu Hospital Enugu over a 10-year period (1993-2003) was identified from the theater register. All these patients were found to have been assessed by the author. The interval between the onset of scrotal pain and presentation at the hospital (for every patient) was recorded. The nature of the scrotum and contralateral testis was also noted. The time of starting operation was taken as the time of scrotal incision.
At operation, twisted testes were untwisted and if viable, fixed with nonabsorbable suture; or excised if nonviable. The contralateral testes were also fixed, because about 40% of patients who suffer torsion have the predisposing anatomical abnormality bilaterally. If at scrotal exploration, the patient was found to have epididimyo-orchitis rather than torsion, orchidopexy was not done.
| Results|| |
In all, 22 patients were found to have undergone emergency scrotal exploration. All their case records were retrieved and studied. Their ages ranged from 10 to 38 years with a mean of 22.7 years. Of these 22 patients studied, 16 (72.7%) had testicular torsion, out of which, 12 had viable testes and 4 nonviable. One patient had atrophic testis on the contralateral side and another, an empty contralateral hemiscrotum due to previous orchidectomy [Table 1]. Six (27%) had epididymo-orchitis clinically and were excluded from the study.
|Table 1: Age of patients, interval between onset of symptoms and presentation, physical findings and operative procedure|
Click here to view
The salvage rate of twisted testis depended on the time interval between onset of symptoms and presentation to the surgeon. While one patient came as early as 20 minutes after the onset of symptoms, another waited for as late as 6 weeks [Table 1]. Information collected from the records showed that these patients underwent scrotal exploration in less than 2 hours of arrival at the hospital.
| Discussion|| |
Testicular torsion is thought to be the most frequent among adolescents with 65% of cases presenting between 12 and 18 years of age.  Contrary to this, majority of the patients (68.75%) with testicular torsion in this study were 20 or more years old. There is no ready explanation for this disparity, although Udeh had noted a similar result in a previous study in Enugu. 
A striking finding of this audit was that 56% of the patients came within 6 hours of feeling scrotal pain and that all these patients had scrotal exploration in less than 2 hours after arrival at the hospital [Table 1]. Twelve (75%) had viable testes, unlike the findings of Osegbe et al.  where only 27% had viable testes due to delay in presentation. Rampaul and Hosking reviewing 22 patients in the United Kingdom also noted lateness in presentation as 62% of their came after 6 hours of onset of pain. It is known that early presentation and diagnosis and prompt surgical intervention may reverse testicular ischemia and avert unnecessary orchidectomy. This early diagnosis may involve the use of Doppler ultrasound  where diagnosis of testicular torsion is in doubt and facilities are available. The diagnosis using this investigative tool is based on the finding of decreased or absent blood flow on the affected side.  Delay on the other hand may lead to progressive, time-dependent testicular damage because twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia, leading to infarction of the testicle. How tightly the testicle is twisted appears to correlate with how quickly the testicle becomes nonviable from ischemia. In this study, four patients (25%) had gangrenous testes and all came more than 24 hours after the onset of scrotal pains. Of the patients who presented late [Table 1] surprisingly, one had earlier undergone orchidectomy and another had an atrophic contralateral testis after previous scrotal pain. These two patients however had viable testes at operation. They may have had incomplete torsion or spontaneous untwisting. Factors such as incompleteness of vascular occlusion, spontaneous untwisting, and degree of twist are known to affect the ischemic process.  According to Wampler, there is an excellent chance (90%) of saving the testicle if treated within 6 hours; within 12 hours the rate decreases to 50%, within 24 hours is 10%, and after 24 hours the rate approaches 0. 
A patient in this study had atrophy of one testis when presenting with testicular pain in the contralateral testis, for which he had orchidopexy. This may have resulted from intermittent torsion. Some patients are known to have episodes of recurrent testicular pain from time to time. These episodes are probably due to intermittent torsion.  This may also be dangerous, because biopsies of the testes at times of orchidopexy in some of these patients had demonstrated peritubular fibrosis and frank testicular atrophy, both of which result in azoospermia and infertility.  For these reasons, patients with a history suggesting intermittent torsion are advised to undergo bilateral orchidopexy.  This reduces the risk of testicular infarction. 
To reduce testicular loss, surgeons need to focus attention on public health education to reduce the time wasted between onset of testicular pain and surgical intervention. This effort should include public lectures in places where young males are found in great numbers, e.g., schools, military, and police barracks; drawing attention to the serious nature of acute scrotal pain even for short period of time, and the consequences of neglecting it. Besides, during continuing medical education programs for doctors, emphasis should be stressed on the need for early referral of young patients with acute scrotal pain to the surgeon to avoid needless testicular loss. This is important because one of our patients, who had orchidectomy, had actually been receiving treatment from a physician for epididymo-orchitis. In addition, nurses should be encouraged to give priority to patients presenting at the accident and emergency department with scrotal pain. These patients should be referred to the surgical team without delay. A plea is finally made for these patients to be operated upon in the accident and emergency theater with local anesthetic. This step will eliminate the time taken to transfer these patients to the ward and also to secure a space in the hospital's main operating theater.
| References|| |
|1.||Rampaul MS, Hosking SW. Testicular torsion: Most delay occurs outside hospital. Ann R Coll Surg Engl 1998;80:169-72. |
|2.||Ringdahl E, Teague L. Testicular torsion. Am Fam Physician 2006;74:1739-43. |
|3.||Seng YJ, Moissinac K. Trauma induced testicular torsion: A reminder for the unwary. J Accid Emerg Med 2000;17:381-2. |
|4.||Arce JD, Cortes M, Vargas JC. Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: A key to the diagnosis. Pediatr Radiol 2002;32:485-91. |
|5.||Ugwu BT, Dakum NK, Yiltok SJ, Mbah N, Legbo JN, Uba AF, et al. Testicular torsion on the Jos Plateau. West Afr J Med 2003;22:120-3. |
|6.||Osegbe DN, Ogbunkua O, Magoha GA. Testicular torsion rate in Nigerians. Trop Geogr Med 1987; 39:372-5. |
|7.||Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am 1988;6:521-46. |
|8.||Udeh FN, Testicular torsion: Nigerian experience. J Urol 1985;134;3:482-4 |
|9.||Kapoor S. Testicular torsion: A race against time Int J Clin Pract. 2008;62:821-7. |
|10.||Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care 2010;37:613-26. |
|11.||Sellu DP, Lynn JA. Intermittent torsion of the testis. J R Coll Surg Edinb 1984;29:107-8. |
|12.||Eaton SH, Cendron MA, Estrada CR, Bauer SB, Borer JG, Cilento BG, et al. Intermittent testicular torsion: Diagnostic features and management outcomes. J Urol 2005;174:1532-5 discussion 1535. |