TESTIS TESTICULAR APPENDAGES TORSION

Torsion of the testis and testicular appendages
Definition
A testicular torsion is a twist of the spermatic cord resulting in strangulation of the blood supply to the testis and epididymis. Testicular torsion occurs most frequently between the ages of 10 30 (peak incidence 13 15 years of age), but any age group may be affected.

History and examination
Sudden onset of severe pain in the hemiscrotum, sometimes waking the patient from sleep. It may radiate to the groin, loin, or epigastrium (reflecting its origin from the dorsal abdominal wall of the embryo and its nerve supply from T10/11). There is sometimes a history of minor trauma to the testis. Some patients report previous episodes with spontaneous resolution of the pain (suggesting previous torsion with spontaneous detorsion). The patient may have a slight fever. The testis is usually slightly swollen and very tender to touch. It may be high-riding (lying at a higher than normal position in the testis) and may be in a horizontal position due to twisting of the cord.

Differential diagnosis and investigations
Epididymo-orchitis, torsion of a testicular appendage, and causes of flank pain with radiation into the groin and testis (e.g. a ureteric stone). Colour doppler ultrasound (reduced arterial blood flow in the testicular artery) and radionuclide scanning (decreased radioisotope uptake) can be used to diagnose testicular torsion, but in many hospitals these tests are not readily available and the diagnosis is based on symptoms and signs.

Surgical management
Scrotal exploration should be undertaken as a matter of urgency. Delay in relieving the twisted testis results in permanent ischaemic damage to the testis causing atrophy, loss of hormone and sperm production, and, as the testis undergoes necrosis and the blood testis barrier breaks down, an autoimmune reaction against the contralateral testis (sympathetic orchidopathia). Fix BOTH testes since the bell-clapper abnormality which predisposes to torsion can occur bilaterally.

Torsion of testicular appendages
The appendix testis (hydatid of Morgagni a remnant of the Mullerian duct) and the appendix epididymis (a remnant of a cranial mesonephric tubule of the Wolffian duct) can undergo torsion causing pain that mimicks a testicular torsion. At scrotal exploration they are easily removed with scissors or a diathermy probe.