Testicular torsion
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With testicular torsion, the testicle twists around its longitudinal axis on the spermatic cord. This constricts the blood vessels that supply the testicles. A testicular torsion is very painful; without prompt treatment, the gonad can die. Usually the torsion is operated on, sometimes an external rotation through the skin of the scrotum is sufficient. Read all about the causes, symptoms and treatment of testicular torsion!
ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. N44
Testicular torsion: description
The testicular torsion (also testicular twisting or twisting of the testicles) around the longitudinal axis of the spermatic duct and vascular cord is a dangerous complication because it can constrict or completely cut off the blood supply to the testicle.
If the testicular rotation only constricts the vein (vena testicularis) and thus the venous drainage, while the artery (arteria testicularis) continues to pump blood to the testicle due to the higher blood pressure in it, an incomplete torsion is present. The blood builds up in the testicles, which can then also impair the arterial inflow. This can lead to the death of testicular tissue (hemorrhagic testicular necrosis).
If the testicular torsion interrupts both the venous outflow and the arterial supply of blood from the outset, it is referred to as complete torsion. Here, too, tissue death quickly occurs.
If both testicles are twisted at the same time, this is known as bilateral testicular torsion.
In principle, testicular torsion is possible at any age, but occurs especially in the first year of life and between the ages of 12 and 18. With increasing age, testicular torsion becomes less and less common.
There are two main types of testicular torsion: extravaginal and intravaginal testicular torsion.
Extravaginal testicular torsion
This variant is the most common. It occurs mainly in babies and toddlers before the age of two: the spermatic cord then twists above the testicular membrane, a connective tissue pocket in which the testicle rests in the scrotum.
Intravaginal testicular torsion
This type of testicular twisting, which is more common in adolescents, occurs within the testicular membrane and thus closer to the testicle itself. Here, too, the blood supply is disturbed or interrupted by the twisting of the spermatic cord.
Hydatide torsion
The so-called hydatid torsion, in which residual structures attached to the testicle from the embryonic period twist, is not a real testicular torsion. The symptoms are similar to those of testicular torsion, but are often less severe. Damage to the testicular tissue itself does not initially occur, however, testicular tissue can also be affected by the dead testicular appendages and blood poisoning can result.
Testicular torsion: symptoms
The main symptom of testicular torsion is sudden pain in the affected side of the scrotum. The pain usually increases significantly when pressure is applied or often when it is simply touched, and it can also radiate into the inguinal canal and / or lower abdomen on the corresponding half of the body.
Sometimes the typical symptoms are accompanied by vegetative complaints. These include nausea and vomiting, sweating and an accelerated heart rate up to shock. Without treatment for testicular torsion, the testicles continue to swell and the skin of the scrotum turns red.
About a third of patients with testicular torsion first experience repeated incomplete torsions, with only fleeting symptoms that disappear again because the affected testicle spontaneously rotates back. This does not seem to result in permanent damage, but the risk of testicular torsion requiring treatment increases.
A special case is the twisting of the testicles in infants, because they indicate pain by screaming, but cannot show the location of the pain. Diffuse abdominal pain, umbilical colic, motor restlessness, vomiting, and refusal to eat can indicate testicular torsion.
A testicle twist can also occur with a testicle that has not descended (not descended): The testicles arise in the abdomen and usually descend into the scrotum until birth. Sometimes this descent does not occur - one or both testicles remain in the abdomen (abdominal testicles) or only migrate into the inguinal canal (inguinal testicles). A torsion in a testicle that has not descended is difficult to diagnose. The twisting of a right-sided abdominal testicle is often mistaken for acute appendicitis due to the diffuse symptoms. In the case of torsion of an inguinal testicle, painful swelling occurs in the groin area with reddening and overheating.
Testicular torsion: causes
A prerequisite for testicular torsion is usually overmobility of the testes within their sheaths and their suspension due to anatomical anomalies. Small triggers are often enough to cause testicular torsion.
Anatomical risk factors for testicular torsion
A risk factor for testicular torsion is, for example, the incorrect placement of the testicular sheaths, for example if they do not stick together sufficiently in the course of development. This gives the flat, oval testicles too much freedom of movement. The result is usually an intravaginal testicular torsion.
In addition, testicular torsion is favored if the so-called lower gonadal ligament is insufficiently developed or not developed at all. This structure, known as the gabernaculum testis, is used to pull the testicles down into the scrotum after birth (testicular descent or descensus testis). It then forms around two ligaments that hold the testicle in place. An incomplete testicular descent (also undescended testicle or Maldecensus testis) is a risk factor for testicular torsion.
A slender muscle (Musculus cremaster) runs together with the vas deferens and the vessels, which pulls the testicles towards the body to regulate temperature, to protect against injury or in the event of great sexual arousal. If its attachment to the testicle is unfavorable, its reflex-like contraction can encourage twisting of the testicle.
Finally, previous operations on the scrotum or testicles can also favor testicular torsion. For example, if the testicle is not optimally repositioned during a so-called water break, it can increase the risk of testicle twisting.
Direct triggers for testicular torsion
If the anatomical risk factors are pronounced, testicular torsion can occur very quickly - even when moving during sleep.
In addition, any physical activity can cause testicular torsion as soon as the testicles move. Therefore, the injury often occurs while exercising or playing. Cycling is a special risk factor because the testicles are constantly "rolling" over the nose of the bicycle saddle.
Testicular torsion: examinations and diagnosis
If testicular torsion is suspected, the doctor should examine the patient immediately. Relevant background information such as the beginning and intensity of the symptoms, known undescended testicles, previous or accompanying infections (especially viral infections) can be obtained by the doctor from the parents or, in the case of older patients, from them themselves.
Physical examination
The doctor examines the affected testicle and looks for things like swelling, redness, asymmetry (compared to healthy testicles) and bruises. The groin region and the abdomen (abdomen) are also examined in order to identify any diseases that radiate with their symptoms to the testicles.
Special tests can confirm or disprove suspected testicular torsion:
If the pain remains unchanged or even worsens when the affected testicle is lifted (negative Prehn's sign), this indicates testicular torsion. This test is primarily used to rule out inflammation of the testicles / epididymis (orchitis / epididymitis), in which the pain is reduced by lifting the scrotum (Prehn's sign positive).
The doctor can also test the cremaster reflex: when it strokes the inside of the thigh, the cremaster muscle normally contracts reflexively and thereby pulls the testicle up on that side. This is not the case with testicular torsion. It should be noted, however, that the cremaster reflex is less clearly triggerable in infants and adolescents than in adults.
By standing up the twisted testicle, the skin of the scrotum is pulled inwards. This is called the "Ger sign".
The "Tenkhoff symbol" is a kind of crackling sound when the scrotum is touched. It also indicates a twisted testicle.
Laboratory examination
In order to exclude inflammation (such as testicular inflammation, epididymis, urinary tract infection) as the cause of the symptoms, laboratory tests are useful. Important inflammatory parameters such as C-reactive protein, leukocytes and the rate of sedimentation are measured in the blood. The urine can be examined for bacteria and sediments.
Imaging diagnostics
The most reliable examination for suspected testicular torsion is sonography (ultrasound). It allows an assessment of the condition of the testicular tissue and can show swellings and blocked blood vessels. A supplement to the examination is Doppler sonography, which can show the blood flow in the testicular vessels. Both examinations, however, require a great deal of experience and should be carried out by a urological specialist.
Testicular torsion can also be detected with a testicular scintigraphy. This special type of X-ray examination measures whether and how quickly a radioactive contrast agent is distributed in the testicular tissue. With testicular torsion, this process is delayed or does not take place at all. This method is not routinely used to clarify testicular torsion, among other things because of the radiation exposure.
Magnetic resonance tomography (MRT) can also be used to display diseases of the testicles such as twisted testicles very reliably. Because the examination is very time-consuming, not possible everywhere and very expensive, it is not a routine examination for testicular torsion.
If the results of an apparatus-based diagnosis are inconclusive, but the symptoms suggest a testicular twist, appropriate treatment should be initiated.
Testicular torsion: treatment
The top priority in the treatment of testicular torsion is speed! The more time it takes for the blood supply to be restored, the more likely it is that the testicle will be lost. In specialist books and studies, this time is estimated at six to eight hours, so a testicle-preserving procedure should be carried out as early as possible.
Open therapy for testicular torsion
Testicular torsion is almost always treated surgically - preferably within the first four to six hours. To do this, the doctor opens the scrotum directly or through the inguinal canal. If the testicle is exposed, it must determine the direction of the testicle twist and turn the testicle back into its original position accordingly.
To determine whether the testicle has recovered, you wait up to 30 minutes and check whether the blood flow in the vessels starts again. If not, testicular tissue has already died and the necrotic testicle must be removed.
If it is not clear to what extent the testicle has already been damaged, it is usually left in the scrotum. It is believed that even if the testicular tissue is partially destroyed, there is still a certain residual function that can contribute to the production of hormones and sperm cells.
Now the testicle is fixed at the bottom of the scrotum to reduce the risk of it twisting again. This is called orchidopexy. This attachment is necessary because otherwise the risk of renewed testicular torsion would be particularly high. Orchidopexy does not completely rule out further rotation.
Since those affected are also more likely to twist the testicles on the opposite side, the testicle is also sutured to the scrotum there - usually within the same operation. However, this procedure is postponed if the twisted testicle has already been severely damaged in order not to complicate the healing process.
After the operation, the testicles should be cooled to relieve pain and placed on a so-called testicular bench. These are very soft cushions that are pushed under the scrotum while lying down.
The non-operative therapy of testicular torsion
Testicular torsion can sometimes be treated without surgery. An experienced examiner then tries to turn the testicle back through the skin using handles from the outside. If this promptly eases the pain and everything appears normal again when you palpate, this speaks for the success of the treatment. In any case, both testicles should be sutured to the scrotum within 12 to 24 hours (orchidopexy) to avoid further testicular torsion.
Due to the great uncertainty of the procedure, manual therapy is not used as an alternative to surgical treatment, but rather as an initial treatment in emergency situations, if a prompt operation is not possible for certain reasons.
Testicular torsion: disease course and prognosis
If testicular torsion is treated within the first few hours of symptoms appearing, the testicle will usually recover completely. However, the longer the blood supply was interrupted, the lower the chances of maintaining functional testicular tissue.
A testicular torsion that has existed for a long time can also endanger the testes on the other side, because certain vascular reflexes and messenger substances can also impair its blood supply. So-called autoantibodies, which are actually directed against dead testicular tissue, can also attack healthy testicles (contralateral testicular damage).
In 36 to 39 percent of patients with testicular torsion, fertility is limited.
After a testicular rotation, a bilateral orchidopexy should always be performed. Attachment to the scrotum tissue can significantly reduce the risk of testicular torsion again.
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