TORSION OF THE TESTICLE

Testicular torsion refers to the twisting of a testicle within the scrotal sac. This twisting can happen randomly and without warning in males of all ages. Whenever it occurs, testicular torsion is associated with pain and swelling. The two peak times of occurrence are before birth and in the early teenage years. While timely surgical intervention can save the testes in older boys, this is not possible when the torsion occurs before birth. It is important to remember that if torsion ruins one testicle, the opposite testicle is at risk for a similar torsion event. Once testicular torsion occurs, the scrotum immediately swells up and becomes quite reddened. If untreated the pain from testicular torsion will subside in a week or two and the scrotal swelling gradually resolves as well. In a baby with torsion occurring before birth the testes can demonstrate a normal sized but very firm testes when the boys is examined in the delivery room. Four months after untreated torsion, the involved testes is usually quite small, even "BB sized" and, again, very, very firm. The opposite testes may become larger than normal to compensate for the loss of the other testicle.

In our practice of Pediatric Urology we see many boys with a wide variety of genital problems. Often infants are referred to us for evaluation of "undescended" testes. Occasionally we detect a "BB" sized nubbin in one scrotal sack with compensating enlargement of the other testicle; both good clues to the proper diagnosis of prenatal torsion. Parents of these boys are naturally confused when we inform them of the possibility that the "undescended" testes is really properly located in the scrotum but likely shriveled up and of no value due to this occurrence of prenatal testicular torsion. Their concern is increased considerably when we then direct the our discussion to the possibility that their son’s only good testes is at risk for suffering the same fate. That is, we believe that a boy who has had pre-natal torsion on one side is at risk, forever, for experiencing the same problem on the good side. Because of this belief we recommend that the boy have surgery to "tack" down the good testicle to protect it from future harm from testicular torsion. While it would be awful to injure such a testes with a surgical complication, we believe the risks of such complications are justified. When a newborn boy is diagnosed with prenatal torsion, we do not recommend immediate surgery as is done when the diagnosis is made in teenage boys. We do make sure that parents and all care providers check the good testes at every diaper change in order to make sure that there are no problems with the boy's one and only testicle. When the torsion occurs before birth, salvage is not possible and surgery in a newborn would have its own risks. Generally we wait until the boy is 6 to 9 months old and then we recommend that the boy undergo a "tacking down" of his good testicle to protect it from subsequent torsion.

Signs and Symptoms

Testicular torsion presents with scrotal swelling and pain. The patient is usually in severe pain and can also be sick with symptoms of nausea and vomiting. The scrotum is very swollen and reddened in color. With these symptoms immediate travel to the emergency room for an ultrasound of the scrotum to rule out torsion is necessary. Performing surgery on the torsed testicle within six hours of the onset of pain and swelling can (but not always) reverse testicular torsion and save the testicle; unless the patient is aware of these warning signs and takes prompt action, the testes is often lost.

TORSION OF THE APPENDIX TESTIS

There is a difference between torsion of the entire testicle and torsion of the appendix testis. Torsion of the appendix testis is a harmless condition and not a surgical emergency. The appendix testis (see diagram) is a small pea size structure on the top of the testicle. It is possible for this small little piece of tissue to twist on its tiny stalk and cause significant pain and swelling in the scrotum. A careful examination by the Pediatric Urologist can often lead to the diagnosis of torsed appendix testes (harmless) and not torsion of the testes itself (requiring immediate surgery). If there is enough pain and swelling present to not allow a correct diagnosis, doctors often rely on the scrotal ultrasound to tell the difference. Generally with torsion of the appendix testes, the ultrasound shows a normal testicle with increased blood flow to the structures next to the testicle. This ultrasound appearance suggests that there is an infection present, but infections are so infrequent in boys that given a healthy testes and increased blood flow to the structures next to the testes the most likely diagnosis is torsed appendix testes. Boys so affected get better in 4 to 6 days with restricted activity, ice packs and anti-inflammatory medication. Increased activity makes the condition much worse so it is important to keep the boy doing quiet activities while he is healing up a torsed appendix testis.