Testicular torsion is a twisting of a testicle that cuts blood flow in the testicular artery that feeds testicle. It is a medical emergency that requires immediate attention.
The tunica vaginalis is a membrane that encloses a testicle and stabilizes it by attaching it to an internal fascia, a fibrous connective tissue. Arteries and the spermatic cord run through the tunica to the testicle. Put a tennis ball in a sock and grasp it just above the tennis ball. The sock is the tunica vaginalis and the ball is the testicle. When the sock is grasped tightly directly above the tennis ball, the ball is relatively stable. If the sock is grasped at a short distance from the ball, the ball can twist. In about 12% of men the tunica (the sock) is attached a little higher than normal which gives the testicle an added degree of freedom. This is called a “bell clapper abnormality.” When the testicle rotates it twists the arteries and cuts blood flow to the testicle. The testicle can survive only a few hours without blood. This is why the condition requires immediate care.
The problem may strike about 1 in 4,000 males in the U.S. annually, most of whom are under 30 years old. The majority of those affected are between the ages of 12 and 18. The peak age is 14. About half the instances of testicular torsion occur during sleep and are thought to be caused by muscle spasms. A large percentage of torsion events are tied to physical activity or an injury.
The most common symptom is a sudden onset of pain in the scrotum that holds the testicles. Sometimes the pain grows slowly but this is not usual. The scrotum will swell. About a third of men will experience nausea and vomiting and perhaps a third will experience abdominal pain. Up to 16% will develop a fever and a small percentage (4%) will have the urge to urinate.
The symptoms are highly suggestive of the problem. An examining physician can often diagnose the problem from the symptoms and by palpating (feeling) the testicles. When these measures do not yield a positive diagnosis, color doppler ultrasonography may be used to determine if blood is flowing the testicle and where the blockage might be. Sonography bounces sound waves off of tissues and structures and uses the echoes to form an image, a sonogram.
Mild analgesics are usually administered to reduce pain once the problem has been diagnosed. Some physicians will delay analgesics and use the relief of the pain to indicate that the problem has been resolved. The physician stands at the patient’s feet, grasps the testicle between the thumb and forefinger and manually rotates it back to its proper position. This will resolve the problem in about 70% of cases. When surgery is needed, an incision is made in the scrotum and the testicle is rotated. The surgeon may then place a few sutures in the testicle and the adjacent testicle to stabilize them and prevent the problem from recurring. When these procedures are conducted soon after the problem appears, nearly all patients will recover.
If action is delayed and the blood supply to the testicle is interrupted for 6 hours or longer, the testicle may atrophy and need to be removed. In some instances the testicle may atrophy even after the problem has been corrected. The absence of one testicle does not reduce sexuality or prevent a man from fathering children. The absence of blood flow for a prolonged period also increases the risk of infection to the testicle and scrotum.
However, if the problem occurs, timely treatment is essential. Patients who suspect they may have testicular torsion should seek treatment at the closest medical facility or emergency department.