http://ekaartha.blogspot.com/2011/05/torsio-testis.html

DefinisiTorsio testis adalah terpeluntirnya funikulus spermatikus yang berakibat terjadinya oklusi dan strangulasi dari vaskularisasi vena atau arteri ke testis dan epididymis serta bisa mengakibatkan infark. Torsi testis ini merupakan kasus gawat darurat di bidang urologi dan membutuhkan diagnosis dan intervensi yang cepat untuk menjaga klengsungan hidup dari testis serta memerlukan tindakan bedah yang segera. Jika kondisi ini tidak ditangani dalam waktu singkat (dalam 4 hingga 6 jam setelah onset nyeri) dapat menyebabkan infark dari testis, yang selanjutnya akan diikuti oleh atrofi testis.

Torsio testis bisa terjadi pada semua usia, tetapi paling sering terjadi pada usia dewasa muda (usia 10-30 tahun) dan lebih jarang terjadi pada neonatus. Puncak insiden terjadi pada usia 13-15 tahun. Peningkatan insiden selama usia dewasa muda mungkin disebabkan karena testis yang membesar sekitar 5-6 kali selama pubertas. Testis kiri lebih sering mengalami torsi dibandingkan dengan testis kanan, hal ini mungkin disebabkan oleh karena secara normal spermatic cord kiri lebih panjang. Pada kasus torsio testis yang terjadi pada periode neonatus, 70% terjadi pada fase prenatal dan 30% terjadi postnatal.

Etiologi• Perubahan suhu secara mendadak (saat berenang)• Ketakutan• Latihan yang berlebihan• Batuk• Celana yang terlalu ketat• Defekasi• Trauma yang mengenai skrotum

PatofisiologiTerdapat 2 jenis torsio testis berdasarkan patofisiologinya yaitu torsio intravagina dan ekstravagina. Torsio intravagina terjadi di dalam tunika vaginalis dan disebabkan oleh karena abnormalitas dari tunika pada spermatic cord di dalam scrotum. Secara normal, fiksasi posterior dari epididymis dan investment yang tidak komplet dari epididymis dan testis posterior oleh tunika vaginalis memfiksasi testis pada sisi posterior dari scrotum. Kegagalan fiksasi yang tepat dari tunika ini menimbulkan deformitas, dan keadaan ini menyebabkan testis mengalami rotasi pada cord sehingga potensial terjadi torsio. Torsio ini lebih sering terjadi pada usia remaja dan dewasa muda.Torsio ekstravagina terjadi bila seluruh testis dan tunika terpuntir pada axis vertical sebagai akibat dari fiksasi yang tidak komplet atau non fiksasi dari gubernakulum terhadap dinding scrotum, sehingga menyebabkan rotasi yang bebas di dalam scrotum. Kelainan ini sering terjadi pada neonatus dan pada kondisi undesensus testis

PathogenesisOtot kremaster berfungsi menggerakkan testis mendekati dan menjauhi rongga abdomen untuk mempertahankan suhu ideal untuk testis. Adanya kelainan system penyanggah testis menyebabkan testis dapat mengalami torsio jika bergerak secara berlebihan.Terpeluntirnya funikulus spermatikus menyebabkan obstruksi aliran darah testis sehingga testis mengalami hipoksia, edema testis,dan iskemia. Akhirnya testis dapat

mengalami nekrosis. Torsio testis lebih sering terjadi pada anak. Torsio testis terjadi pada anak dengan insersi tunika vaginalis tinggi di funikulus spermatikus sehingga funikulus dengan testis dapat terpuntir di dalam tunika vaginalis. Akibatnya terjadi gangguan perdarahan testis mulai dari bendungan vena sampai iskemia yang menyebabkan gangrene.Manifestasi klinis dan DiagnosisAnamnesis• Pasien biasanya mengeluh nyeri yang sangat hebat dengan onset tiba-tiba dan pembengkakan testis. Nyerinya bisa menyebar ke lipat paha dan perut bagian bawah, sehingga sering dikelirukan dengan appendicitis kecuali jika dilakukan pemeriksaan fisik pada genetalia secara teliti.• Akut skrotum : nyeri hebat di daerah skrotum, yang sifatnya mendadak dan diikuti pembengkakan pada testis. • pyrexia sangat jarang ditemukan kecuali kalau kemunculannya lambat dan testic mengalami nekrosis.• Nyeri disertai dengan mual dan muntah• Pada bayi gejalanya tidak khas yaitu gelisah, rewel, atau tidak mau menyusui. 

Pemeriksaan fisis• Testis membengkak• Pada torsio testis yang baru terjadi, dapat diraba adanya lilitan atau penebalan funikulus spermatikus.• Skrotum biasanya membengkak dan berwarna merah atau biru. • Testis yang sakit bisa juga terlihat lebih tinggi dan melintang pada skrotum dibandingkan dengan testis pada sisi yang normal. Pembengkakan itu juga sangat sakit bila disentuh. • Tingkat usia sering dipakai sebagai kriteria untuk membedakan torsi dengan epididimitis, karena torsi biasanya terjadi pada massa pubertas sedangkan epididimitis sering terjadi pada usia sexual aktif yaitu biasanya lebih dari 20 tahun.• Pada pemeriksaan fisik Sangat susah untuk membedakan testis dari epididimis karna telah terjadi pembengkakan. Karena alasan ini, keadaan ini sering mengalami salah diagnosis dengan epididimitisPemeriksaan penunjang• Pemeriksaan sedimen urin tidak menunjukkan adanya leukosit• Pemeriksaan darah tidak menunjukkan tanda inflamasi• Stetoskop Doppler, ultrasonografi Doppler, dan sintigrafi testis. Semuanya bertujuan menilai adanya aliran darah ke testis. Pada torsio testis tidak didapatkan adanya aliran darah ke testis.Diagnosis torsi testis dibuat berdasarkan kecurigaan klinis yang diperoleh dari hasil anamnesis dan pemeriksaan fisik termasuk dengan eksplorasi skrotum. Akan tetapi jika masih meragukan, color Doppler ultrasound atau nuclear testicular scan bisa digunakan untuk membantu dalam menegakan diagnosis. Pada kasus torsi testis, pemeriksaan Doppler ultrasound tidak ditemukan adanya aliran darah, dan pada pemeriksaan scan radionuclide terjadi radionuclide tracer uptake yang rendah. Sedangkan pada kasus epididymo-orchitis, Doppler ultrasound akan memperlihatkan peningkatan aliran darah, dan radionuclide akan memperlihatkan peningkatan aktivitas radionuclide.Jika ditemukan riwayat serangan nyeri skrotum dengan onset yang tiba-tiba dan intermiten pada anak laki-laki, diagnosis torsi intermiten dapat dipertimbangkan.

PengobatanSekali diagnosis torsio testis ditegakkan, maka diperlukan tindakan pemulihan aliran darah ke testis secepatnya. Biasanya keadaan ini memerlukan eksplorasi pembedahan. Pada waktu yang sama ada kemungkinan untuk melakukan reposisi testis secara manual sehingga dapat dilakukan operasi elektif selanjutnya. Namun, biasanya tindakan ini sulit dilakukan oleh karena sering menimbulkan nyeri akut selama manipulasi. Pada umumnya terapi dari torsio testis tergantung pada interval dari onset timbulnya nyeri hingga pasien datang. Jika pasien datang dalam 4 jam timbulnya onset nyeri, maka dapat diupayakan tindakan detorsi manual dengan anestesi lokal. Prosedur ini merupakan terapi non invasif yang dilakukan dengan sedasi intravena menggunakan anestesi lokal (5 ml Lidocain atau Xylocaine 2%). Tindakan non operatif ini tidak menggantikan explorasi pembedahan. Jika detorsi manual berhasil, maka selanjutnya tetap dilakukan orchidopexy elektif dalam waktu 48 jam. Analgesik yang adekuat, contohnya pethidine Intra muscular merupakan hal yang sangat essensial. Perubahan iskemia yang irreversible terjadi setelah 6 jam dari torsi. Jika testis menghitam dan gagal melakukan perbaikan setelah beberapa menit, tindakan bedah perlu dilakukan. Tindakan bedah yang dilakukan segera dalam 4-6 jam setelah terjadinya nyeri, rata-rata testis yang bisa diselamatkan adalah sekitar 90 %. Oleh karena itu, jika data-data untuk menegakan diagnosis berlimpah(dapat dipercaya), Pembedahan tidak boleh ditunda.Orchiopexy merupakan cara pmbedahan yang bisa digunakan untuk memperbaiki testis pada dinding skrotum dengan tiga poin berbeda. Predisposisi anatomi pada torsi yang mempengaruhi kedua testis; sehingga, Testis kontralateral juga mengalami perbaikan yang sama. Jika testis menghitam dan gagal melakukan perbaikan setelah beberapa menit, orchidectomy perlu dilakukan. Terdapat bukti yang menyatakan bahwa bisa terjadi kematian testis akibat reaksi imun pada tetis normal yang kontralateral, kemudian selanjutnya bisa berpengaruh pada fungsi hormonal dan spermatogenic pada testis yang berlawanan.Pada kasus dengan torsi intermiten, pasien dapat dipertimbangkan untuk diberian profilaksis bilateral orchidopexies.

Komplikasi Torsio testis dan spermatic cord akan berlanjut sebagai salah satu kegawat daruratan dalam bidang urologi. Keterlambatan lebih dari 6-8 jam antara onset gejala yang timbul dan waktu pembedahan atau detorsi manual akan menurunkan angka pertolongan terhadap testis hingga 55-85%. Putusnya suplai darah ke testis dalam jangka waktu yang lama akan menyebabkan atrofi testis Atrofi dapat terjadi beberapa hari hingga beberapa bulan setelah torsio dikoreksi. Insiden terjadinya atrofi testis meningkat bila torsio telah terjadi 8 jam atau lebih. Komplikasi lain yang sering timbul dari torsio testis meliputi:• Infark testis• Hilangnya testis• Infeksi• Infertilitas sekunder• Deformitas kosmetik

Prognosis Jika torsio dapat didiagnosa secara dini dan dilakukan koreksi segera dalam 5-6 jam, maka akan memberikan prognosis yang baik dengan angka pertolongan terhadap testis

hampir 100%. Setelah 6 jam terjadi torsio dan gangguan aliran darah, maka kemungkinan untuk dilakukan tindakan pembedahan juga meningkat.Namun, meskipun terjadi kurang dari 6 jam, torsio sudah dapat menimbulkan kehilangan fungsi dari testis. Setelah 18-24 jam biasanya sudah terjadi nekrosis dan indikasi untuk dilakukan orchi dectomy. Orchidopexy tidak memberikan jaminan untuk tidak timbul torsio di kemudian hari, meskipun tindakan ini dapat menurunkan kemungkinan timbulnya hal tersebut.Keterlambatan intervensi pembedahan akan memperburuk prognosis serta meningkatkan angka kejadian atrofitestis

DAFTAR PUSTAKA

Tanagho, Emil A. dan Jack W. McAninch. 2008. Smith’s General Urology 17th ed. Mc Graw HillWein.dkk. 2007. Campbell-Walsh Urology, 9th ed. Saunders. An Imprint of ElsevierTownsend. 2007. Sabiston Textbook of Surgery, 18th ed. Saunders, An Imprint of Elsevier Bunicardi, F.Charles. dkk.2007. Schwartz's Principles of Surgery 8th edition. McGraw-Hill Companies Purnomo, Basuki B. Dasar-Dasar Urologi Edisi kedua. Jakarta : Sagung Seto : 2009Sjamsuhidajat, R., De jong, wim. Buku Ajar Ilmu Bedah. Jakarta : EGC : 2005.Diposkan oleh Eka Artha Muliadi di 20.17 

http://emedicine.medscape.com/article/2036003-overview

BackgroundTesticular torsion refers to the torsion of the spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle. This is a urological emergency; early diagnosis and treatment are vital to saving the testicle and preserving future fertility.

Testicular torsion is primarily a disease of adolescents and neonates. It is the most common cause of testicular loss in these age groups. Surgical treatment may prevent further ischemic damage to the testis. Rarely, observation is appropriate, depending on the pathology. Diagnosis of testicular torsion is clinical, and diagnostic testing should not delay treatment.

Testicular torsion is caused by twisting of the spermatic cord and the blood supply to the testicle (see the image below). With mature attachments, the tunica vaginalis is attached securely to the posterior lateral aspect of the testicle, and, within it, the spermatic cord is not very mobile. If the attachment of the tunica vaginalis to the testicle is inappropriately high, the spermatic cord can rotate within it, which can lead to intravaginal torsion. This defect is referred to as the bell clapper deformity. This occurs in about 17 % of males[1] and is bilateral in 40%.

Intravaginal torsion most commonly occurs in adolescents. It is thought that the increased weight of the testicle after puberty, as well as sudden contraction of the cremasteric muscles (which inserts in a spiral fashion into the spermatic cord), is the impetus for acute torsion.[1]

By contrast, neonates more often have extravaginal torsion. This occurs because the tunica vaginalis is not yet secured to the gubernaculum and, therefore, the spermatic cord, as well as the tunica vaginalis, undergo torsion as a unit. Extravaginal torsion is not associated with bell clapper deformity. This can occur up to months prior to birth and, therefore, is managed differently depending on presentation.[1] Of course, neonates can have intravaginal torsion and this should be managed in the same manner as adolescents.

Testicular torsion is associated with testicular malignancy, especially in adults; one study found a 64% association of testicular torsion with testicular malignancy. This is thought to be secondary to a relative increase in the broadness of the testicle compared with its blood supply.[1]

Testicular torsion: (A) extravaginal; (B) intravaginal.For patient education information, see the Men's Health Center, as well asTesticular Pain.

For additional information, see Testicular Torsion in Emergency Medicine andPediatric Testicular Torsion .

AnatomyThe testes are paired ovoid structures that are housed in the scrotum and positioned so that the long axis is vertical. The testicle is covered by the tunica vaginalis. Beneath the tunica vaginalis is the capsule of the testis, termed the tunica albuginea. See Male Reproductive Organ Anatomy.

The anterolateral two thirds of the organ is free of any scrotal attachment. There is a potential space here, between the tunica vaginalis and the tunica albuginea, where fluid from a variety of sources may accumulate. The tunica vaginalis attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum.

The epididymis, connective tissue, and vasculature cover the posterolateral aspect of the organ.

The contents of the spermatic cord include the following:

Ductus deferens and associated vasculature and nerves Testicular artery Pampiniform plexus, which ultimately forms the testicular vein Genital branch of the genitofemoral nerve

Testicular descent

For normal development and optimal sperm production, the testis must descend from its original position near the kidney into the scrotum. Researchers propose that various mechanisms, including gubernacular traction and intra-abdominal pressure, are responsible for testicular descent; however, endocrine factors of the hypothalamic-pituitary-testicular axis also play a major role in this process.

Around the 23rd week of gestation, the testis undergoes transabdominal migration to a location near the internal inguinal ring. The testis does not migrate transinguinally to its final position until after the 28th week of gestation, and this is usually complete between the 30th and 32nd week of gestation.[1]

PathophysiologyIn neonates, the testicle frequently has not yet descended into the scrotum, where it becomes attached within the tunica vaginalis. This mobility of the testicle predisposes it to torsion (extravaginal testicular torsion). Inadequate fusion of the testicle to the scrotal wall typically is diagnosed within the first 7-10 days of life.

In males who have an inappropriately high attachment of the tunica vaginalis, as well as abnormal fixation to the muscle and fascial coverings of the spermatic cord, the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly, called the bell clapper deformity, can result in the long axis of the testicle being oriented transversely rather than cephalocaudal.

This congenital abnormality is present in approximately 12% of males and is bilateral in 40% of cases.[2] The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord.

Torsion occurs as the testicle rotates between 90° and 180°, compromising blood flow to and from the testicle. Complete torsion usually occurs when the testicle twists 360° or more; incomplete or partial torsion occurs with lesser degrees of rotation. The degree of torsion may extend to 720°.

The twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle. The degree of torsion the testicle endures may play a role in the viability of the testicle over time.

In addition to the extent of torsion, the duration of torsion prominently influences the rates of both immediate salvage and late testicular atrophy. Testicular salvage is most likely if the duration of torsion is less than 6-8 hours. If 24 hours or more elapse, testicular necrosis develops in most patients.

EtiologyExtravaginal torsion occurs in the fetus or neonate, because the testes may freely rotate prior to the development of testicular fixation via the tunica vaginalis within the scrotum.

Normal testicular suspension ensures firm fixation of the epididymal-testicular complex posteriorly and effectively prevents twisting of the spermatic cord. In males with the bell-clapper deformity, torsion can occur because of a lack of fixation, resulting in the testis being freely suspended within the tunica vaginalis.

An abnormal mesentery between the testis and its blood supply can predispose it to torsion if the testicle is broader than the mesentery. Contraction of the spermatic muscles shortens the spermatic cord and may initiate testicular torsion.

EpidemiologyExtravaginal torsion constitutes approximately 5% of all torsions. Of these cases of testicular torsion, 70% occur prenatally and 30% occur postnatally. The condition is associated with high birth weight. Bilateral perinatal torsion is thought to be rare, although an increase in the number of case reports has been observed. Currently, there are about 56 case reports in the literature.[3]

Intravaginal torsion constitutes approximately 16% of cases in patients presenting to an emergency department with acute scrotum. This form of testicular torsion is most often observed in males younger than 30 years, with most aged 12-18 years. Peak incidence occurs at age 13-14 years. The left testis is more frequently involved. Bilateral cases account for 2% of all torsions.

The incidence of torsion in males younger than 25 years is approximately 1 in 4000.[4] In an Israeli study of pediatric patients presenting to an ED with scrotal/testicular pain of less than 1 week duration, only 17 (3.3%) had testicular torsion.[5]

Several case reports describe familial testicular torsion. In one study of 70 boys with testicular torsion, 11.4% had a positive history in a family member.[6]

PrognosisSuccess in the management of spermatic cord torsion is measured by immediate testicular salvage and the incidence of late testicular atrophy. A recent publication documented that approximately 32% of pediatric torsion cases resulted in the orchiectomy.[7] Increased risk was associated with African American race, younger age, and lack of private insurance. The higher association with younger age may be secondary to delay in diagnosis in young children, who may not be able to communicate the symptoms to caregivers.

The time elapsed between onset of pain and performance of detorsion, and the corresponding salvage rate, is as follows[8, 9] :

< 6 hours – 90-100% salvage rate 12-24 hours – 20-50% > 24 hours – 0-10%

Orchiopexy is not a guarantee against future torsion, though it does reduce the odds of a future torsion.

Consequences of testicular torsion may include the following:

Infarction of testicle Loss of testicle Infection Infertility secondary to loss of testicle Cosmetic deformity

Exocrine and endocrine function is substandard in men with a history of unilateral torsion. A correlation may exist between the duration of torsion and abnormal semen parameters. The following 3 theories explain the contralateral disease noted in torsion patients:

Unrecognized or unreported repeated injury to both testes A preexisting pathologic condition predisposing to both abnormal spermatogenesis and torsion of

the spermatic cord[10]

Induction of pathologic changes in the contralateral testis by retention of the injured testisTo explain the decreased fertility observed in unilateral torsion of the spermatic cord, several specialists suggest an autoimmune mechanism. This hypothesis is based upon knowledge of the blood-testis barrier, which isolates the luminal compartment of the seminiferous tubule; animal studies in which researchers induced experimental allergic orchitis; and comparison of contralateral testicular disease to sympathetic ophthalmia, a cell-mediated immune response.

In fact, clinical experience does not support either inherent bilateral testicular abnormalities or a humoral effect adversely affecting the contralateral testis in patients with unilateral torsion, since the fertility of adults with pre–pubertal testicular torsion does not appear to be reduced.[11]

http://www.ilmupenyakit.com/473/penyakit-testicular-torsion-atau-torsi-testis.html

http://herrysetyayudha.wordpress.com/2011/12/01/torsio-testis-testical-torsion/

BAB I

PENDAHULUAN

Kelainan testis yang cukup sering salah satunya adalah torsio testis ini. Sehingga

perlu adanya pembahasan yang lebih terperinci.

Secara anatomi ,Testis adalah organ genitalia pria yang teletak di skrotum. Ukuran

tetstis pada orang dewasa adalah 4 x 3 x 2.5 cm. dengan volume 15-25 ml

berbentuk ovoid. Kedua buah testis terbungkus oleh jaringan tunika albuginea yang

melekat pada testis. Di luar tunika albugine terdapat tunika vaginalis yang terdiri

atas lapisan viseralis dan parietalis, serta tunika dartos. Otot kremaster yang berada

disekitar testis memungkinkan testis untuk dapat digerakkan mendekati rongga

abdomen untuk mempertahankan temperature testis agar tetap stabil.

Secara histopatologis, testis terdiri atas ± 250 lobuli dan tiap lobulus terdiri atas

tubuli seminiferi. Di dalam tubulus seminiferus terdapat sel-sel spermatogonia dan

sel Sertoli, sedang di antara tubuli seminiferi terdapat sel-sel Leydig. Sel-sel

spermatogonium pada proses spermatogenesis menjadi sel-sel spermatozoa. Sel-sel

Sertoli berfungsi memberi makan pada bakal sperma, sedangkan sel-sel Leydig atau

disebut sel-sel interstisial testis berfungsi dalam menghasilkan hormone

testosterone.

Sel-sel spermatozoa yang diproduksi di tubuli seminiferi testis disimpan dan

mengalami pematangan/maturasi di epididimis. Setelah matur (dewasa) sel-sel

spermatozoa bersama-sama dengan getah dari epididimis dan vas deferens

disalurkan menuju ke ampula vas deferens. Sel-sel itu setelah bercampur dengan

cairan-cairan dari epididimis, vas deferens dan vesikula seminalis, serta cairan

prostate, membentuk cairan semen atau mani.

Testis mendapat darah dari beberapa cabang arteri, yaitu arteri spermatika interna

yang merupakan cabang dari aorta, arteri deferensialis cabang dari arteri vesikalis

inferior, dan arteri kremasterika yang merupakan cabang arteri epigastrika.

Pembuluh vena yang meninggalkan testis berkumpul meninggalkan testis berkumpul

membentuk pleksus Pampiniformis. Pleksus ini pada beberapa orang mengalami

dilatasi dan dikenal sebagai varikokel. (2)

 

BAB II

PEMBAHASAN

I. DEFINISI

Torsio testis adalah terpeluntirnya funikulus spermatikus yang berakibat terjadinya

gangguan aliran darah pada testis. Keadaan ini diderita oleh I diantara 4000 pria

yang berumur kurang dari 25 tahun, paling banyak diderita oleh anak pada masa

pubertas (12-20 tahun). Disamping  itu, tak jarang  janin yang masih berada dalam

uterus atau bayi baru lahir menderita torsio testis yang tidak terdiagnosis sehingga

mengakibatkan kehilangan testis baik unilateral maupun bilateral.(2)

 

Torsio testis atau terpeluntirnya funikulus spermatikus yang dapat menyebabkan

terjadinya strangulasi dari pembuluh darah, terjadi pada pria yang jaringan di sekitar

testisnya tidak melekat dengan baik ke scrotum. Testis dapat infark dan mengalami

atrophy jika tidak mendapatkan aliran darah lebih dari enam jam. (5)

II. ETIOLOGI

Torsio testis terjadi bila testis dapat bergerak dengan sangat bebas. Pergerakan

yang bebas tersebut ditemukan pada keadaan-keadaan sebagai berikut :

1. Mesorchium yang panjang.2. Kecenderungan testis untuk berada pada posisi horizontal.3. Epididimis yang terletak pada salah satu kutub testis. (3)

Selain gerak yang sangat bebas, pergerakan berlebihan pada testis juga dapat

menyebabkan terjadinya torsio testis. Beberapa keadaan yang dapat menyebabkan

pergerakan berlebihan itu antara lain ; perubahan suhu yang mendadak (seperti saat

berenang), ketakutan, latihan yang berlebihan, batuk, celana yang terlalu ketat,

defekasi atau trauma yang mengenai scrotum.

Pada masa janin dan neonatus, lapisan yang menempel pada muskulus dartos masih

belum banyak jaringan penyangganya sehingga testis, epididimis dan tunika

vaginalis mudah sekali bergerak dan memungkinkan untuk terpeluntir pada sumbu

funikulus spermatikus. Terpeluntirnya testis pada keadaan ini disebut torsio

testis ekstravaginal. (2)

Terjadinya torsio testis pada masa remaja banyak dikaitkan dengan kelainan sistem

penyangga testis. Tunika vaginalis yang seharusnya mengelilingi sebagian dari testis

pada permukaan anterior dan lateral testis, pada keadaan ini tunika mengelilingi

seluruh permukaan testis sehingga mencegah insersi epididimis ke dinding skrotum.

Keadaan ini menyebabkan testis dan epididimis dengan mudahnya bergerak di

kantung tunika vaginalis dan menggantung pada funikulus spermatikus. Keadaan ini

dikenal sebagai anomali bell clapper. Keadaan ini menyebabkan testis mudah

mengalami torsio intravaginal. (2)

 

III. GAMBARAN KLINIS/ sign and sympton

Pasien-pasien dengan torsio testis dapat mengalami gejala sebagai berikut :

1. Nyeri hebat yang mendadak pada salah satu testis, dengan atau tanpa faktor predisposisi

2. Scrotum yang membengkak pada salah satu sisi3. Mual atau muntah4. Sakit kepala ringan (7)

Pada awal proses, belum ditemukan pembengkakan pada scrotum. Testis yang

infark dapat menyebabkan perubahan pada scrotum. Scrotum akan sangat nyeri

kemerahan dan bengkak. Pasien sering mengalami kesulitan untuk menemukan

posisi yang nyaman. (6)

Selain  nyeri pada sisi testis yang mengalami torsio, dapat juga ditemukan nyeri alih

di daerah inguinal atau abdominal. Jika testis yang mengalami torsio merupakan

undesendensus testis, maka gejala yang yang timbul menyerupai hernia strangulata.(3)

IV. PEMERIKSAAN FISIK

Dalam phisical examination, Testis yang mengalami torsio letaknya lebih tinggi dan

lebih horizontal daripada testis sisi kontralateral. Kadang-kadang pada torsio testis

yang baru terjadi, dapat diraba adanya lilitan atau penebalan funikulus spermatikus.

Keadaan ini biasanya tidak disertai dengan demam. (2)

Testis kanan dan testis kiri seharusnya sama besar. Pembesaran asimetris, terutama

jika terjadi secara akut, menandakan kemungkinan adanya keadaan patologis di

satu testis. Perubahan warna kulit scrotum, juga dapat menandakan adanya suatu

masalah.  Hal terakhir yang perlu diwaspadai yaitu adanya nyeri atau perasaan tidak

nyaman pada testis. (6)Reflex cremaster secara umum hilang pada torsio testis. Tidak

adanya reflex kremaster, 100% sensitif dan 66% spesifik pada torsio testis. Pada

beberapa anak laki-laki, reflex kremaster dapat menurun atau tidak ada sejak awal,

dan reflex kremaster masih dapat ditemukan pada kasus-kasus torsio testis, oleh

karena itu, ada atau tidak adanya reflex kremaster tidak bisa digunakan sebagai

satu-satunya acuan mendiagnosis atau menyingkirkan diagnosis torsio testis. (5)

V. PEMERIKSAAN PENUNJANG

Pemeriksaan penunjang yang berguna untuk membedakan torsio testis dengan

keadaan akut scrotum yang lain adalah dengan menggunakan stetoskop Doppler,

ultrasonografi Doppler, dan sintigrafi testis, yang kesemuanya bertujuan untuk

menilai aliran darah ke testis.(2)Sayangnya, stetoskop Doppler dan ultrasonografi

konvensional tidak terlalu bermanfaat dalam menilai aliran darah ke testis. Penilaian

aliran darah testis secara nuklir dapat membantu, tetapi membutuhkan waktu yang

lama sehingga kasus bisa terlambat ditangani.  Ultrasonografi Doppler berwarna

merupakan pemeriksaan noninvasif yang keakuratannya kurang lebih sebanding

dengan pemeriksaan nuclear scanning. Ultrasonografi Doppler berwarna dapat

menilai aliran darah, dan dapat membedakan aliran darah intratestikular dan aliran

darah dinding scrotum. Alat ini juga dapat digunakan untuk memeriksa kondisi

patologis lain pada scrotum. (8)

Color Doppler ultrasonogram showing acute torsion

affecting the left testis in a 14-year-old boy who had acute pain for four hours. Note

decreased blood flow in the left testis compared with the right tstis.

Color Doppler ultrasonogram showing late torsion

affecting the right testis in a 16-year-old boy who had pain for 24 hours. Note

increased blood flow around the right testis but absence of flow within the substance

of the testis

Color Doppler ultrasonogram showing inflammation

(epididymitis) in a 16-year-old boy who had pain in the left testis for 24 hours. Note

increased blood flow in and around the left testis

Pemeriksaan sedimen urin tidak menunjukkan adanya leukosit dalam urin, dan

pemeriksaan darah tidak menunjukkan adanya inflamasi kecuali pada torsio yang

sudah lama dan mengalami keradangan steril. (2)

VI. DIAGNOSIS (8,9)

Diagnosis torsio testis dimulai dengan anamnesis, pemeriksaan fisik, dan

pemeriksaan penunjang. Secara umum, digambarkan  pada bagan Alogaritma dan

Clinical Pathway Torsio Testis / Testicular Torsion;

Protocol for the diagnosis and treatment of the acute scrotum.  (8)

VII. DIAGNOSIS BANDING (1,2,4,5)

1. Epididimitis akut. Penyakit ini secara umum sulit dibedakan dengan torsio testis. Nyeri scrotum akut biasanya disertai dengan kenaikan suhu, keluarnya nanah dari uretra, adanya riwayat coitus suspectus (dugaan melakukan senggama dengan selain isterinya), atau pernah menjalani kateterisasi uretra sebelumnya. Pada pemeriksaan, epididimitis dan torsio testis, dapat dibedakan dengan Prehn’s sign, yaitu jika testis yang terkena dinaikkan, pada epididmis akut terkadang nyeri akan berkurang (Prehn’s sign positif), sedangkan pada torsio testis nyeri tetap ada (Prehn’s sign negative). Pasien epididimitis akut biasanya berumur lebih dari 20 tahun dan pada pemeriksaan sedimen urin didapatkan adanya leukosituria dan bakteriuria.

2. Hernia scrotalis incarserata. Pada anamnesis didapatkan riwayat benjolan yang dapat keluar masuk ke dalam scrotum.

3. Hidrokel

4. Tumor testis. Benjolan dirasakan tidak nyeri kecuali terjadi perdarahan di dalam

testis

5. Edema scrotum yang dapat disebabkan oleh hipoproteinemia, filariasis, adanya sumbatan saluran limfe inguinal, kelainan jantung, atau kelainan-kelainan yang tidak diketahui sebabnya (idiopatik).

Perbedaan antara torsio testis, torsio appendix testis dan epididimitis dapat dilihat

pada tabel di bawah ini. (8)

Diagnosis of Selected Conditions Responsible for the Acute Scrotum

Condition

Onset

of

sympt

oms Age

Tender

ness

Urinal

ysis

Cremas

teric

reflex

Treat

ment

Testicular 

torsion

Acute Early

puberty

Diffuse - + Surgica

l

explora

tion

Appendiceal

torsion

Subac

ute

Prepube

rtal

Localize

d to

upper

pole - +

Bed

rest

and

scrotal

elevati

on

Epididymitis

Insidio

us

Adolesc

ence

Epididy

mal + / - +

Antibio

tic

Torsio testis

Torsio appendix testis

Epididimitis

VIII. PENATALAKSANAAN /management

1. Non operatif

Pada beberapa kasus torsio testis, detorsi manual dari funikulus spermatikus dapat

mengembalikan aliran darah. (5)

Detorsi manual adalah mengembalikan posisi testis ke asalnya, yaitu dengan jalan

memutar testis ke arah berlawanan dengan arah torsio. Karena arah torsio biasanya

ke medial, maka dianjurkan untuk memutar testis ke arah lateral terlebih dahulu,

kemudian jika tidak ada perubahan, dicoba detorsi ke arah medial.

Metode tersebut dikenal dengan metode “open book” (untuk testis kanan), Karena

gerakannya seperti membuka buku. Bila berhasil, nyeri yang dirasakan dapat

menghilang pada kebanyakan pasien. Detorsi manual merupakan cara terbaik untuk

memperpanjang waktu menunggu tindakan pembedahan, tetapi tidak dapat

menghindarkan dari prosedur pembedahan. (2,5)

Dalam pelaksanaannya, detorsi manual sulit dan jarang dilakukan. Di unit gawat

darurat, pada anak dengan scrotum yang bengkak dan nyeri, tindakan ini sulit

dilakukan tanpa anestesi. Selain itu, testis mungkin tidak sepenuhnya terdetorsi atau

dapat kembali menjadi torsio tak lama setelah pasien pulang dari RS. Sebagai

tambahan, mengetahui ke arah mana testis mengalami torsio adalah hampir tidak

mungkin, yang menyebabkan tindakan detorsi manual akan memperburuk derajat

torsio.(5)

2. Operatif

Torsio testis merupakan kasus emergensi, harus dilakukan segala upaya untuk

mempercepat proses pembedahan. Hasil pembedahan tergantung dari lamanya

iskemia, oleh karena itu, waktu sangat penting. Biasanya waktu terbuang untuk

pemeriksaan pencitraan, laboratorium, atau prosedur diagnostik lain yang

mengakibatkan testis tak dapat dipertahankan.

Tujuan dilakukannya eksplorasi yaitu :

1. Untuk memastikan diagnosis torsio testis2. Melakukan detorsi testis yang torsio3. Memeriksa apakah testis masih viable4. Membuang (jika testis sudah nonviable) atau memfiksasi jika testis masih viable5. Memfiksasi testis kontralateral

Perbedaan pendapat mengenai tindakan eksplorasi antara lain disebabkan oleh

kecilnya kemungkinan testis masih viable jika torsio sudah berlangsung lama (>24-

48 jam). Sebagian ahli masih mempertahankan pendapatnya untuk tetap melakukan

eksplorasi dengan alasan medikolegal, yaitu eksplorasi dibutuhkan untuk

membuktikan diagnosis, untuk menyelamatkan testis (jika masih mungkin), dan

untuk melakukan orkidopeksi pada testis kontralateral. (5)

 Saat pembedahan, dilakukan juga tindakan preventif pada testis kontralateral. Hal

ini dilakukan karena testis kontralaeral memiliki kemungkinan torsio di lain waktu. (3,5,7)

Jika testis masih viable, dilakukan orkidopeksi (fiksasi testis) pada tunika dartos

kemudian disusul pada testis kontralateral. Orkidopeksi dilakukan dengan

menggunakan benang yang tidak diserap pada tiga tempat untuk mencegah agar

testis tidak terpuntir kembali. Sedangkan pada testis yang sudah mengalami

nekrosis, dilakukan pengangkatan testis (orkidektomi) dan kemudian disusul

orkidopeksi kontralateral. Testis yang telah mengalami nekrosis jika tetap berada di

scrotum dapat merangsang terbentuknya antibodi antisperma sehingga mengurangi

kemampuan fertilitas di kemudian hari. (2)

IX. KOMPLIKASI (5)

1. Atropi testis2. Torsio rekuren3. Wound infection

4. Subfertility

DAFTAR PUSTAKA

(1)   Blandy, John. Lecture Notes on Urology. Third edition. Oxford : Blackwell Scietific

Publication. 1982. 277.

(2)   Purnomo, Basuki P. Dasar-dasar Urologi. Jakarta : Sagung Seto. 2003. 8,145-

148.

(3)   Scott, Roy, Deane, R.Fletcher. Urology Ilustrated. London and New York :

Churchill Livingstone. 1975. 324-325.

(4)   Sjamsuhidajat R, Wim De Jong. Buku Ajar Ilmu Bedah. Edisi ke-2. Jakarta :

Penerbit Buku Kedokteran – EGC. 2004. 799.

(5)   http://emedicine.medscape.com/article/1017689-overview

(6)   http://www.urologyhealth.org/about/

(7)   http://www.nlm.nih.gov/medlineplus/ency/imagepages/1113.htm

(8)   http://www.aafp.org/afp/2006/1115/p1746.html

(9)  http://www.gfmer.ch/selected_images_v2/detail_list.php?

cat1=15&cat2=123&cat3=280&cat4=2&stype=n

(10)  http://www.catscanman.net/blog/2008/12/scan-mans-casebook-case-6/

(11) http://www.catscanman.net/blog/wp-content/uploads/casebook/orchitis5.jpg

(12)   http://urologistchennai.com/services

(13) http://www.medicineonline.com/articles/s/2/Scrotal-Orchiopexy/Testicular-

Torsion-Repair.html

(14)  http://www.surgeryencyclopedia.com/La-Pa/Orchiopexy.html

http://www.mayoclinic.com/health/testicular-torsion/DS01039/DSECTION=complications

DefinitionBy Mayo Clinic staff

Testicular torsion

Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the

scrotum. The reduced blood flow causes sudden and often severe pain and swelling. Testicular

torsion is most common between ages 12 and 16, but it can occur at any age, even before birth.

Testicular torsion usually requires emergency surgery. If treated within a few hours, the testicle can

usually be saved. But waiting longer can cause permanent damage and may affect the ability to father

children. When blood flow has been cut off for too long, a testicle may become so badly damaged it

has to be removed.

SymptomsBy Mayo Clinic staff

Signs and symptoms of testicular torsion include:

Sudden or severe pain in the scrotum — the loose bag of skin under your penis that contains the

testicles

Swelling of the scrotum

Abdominal pain

Nausea and vomiting

A testicle that's positioned higher than normal or at an unusual angle

When to see a doctor 

Seek emergency care for sudden or severe testicle pain. Prompt treatment can prevent severe

damage or loss of your testicle if the cause of the pain is testicular torsion.

You also need to seek prompt medical help if you've had sudden testicle pain that goes away without

treatment. This can occur when a testicle twists and then untwists on its own (intermittent torsion and

detorsion). Even though the testicle untwisted on its own, you still need to see a doctor because

surgery is frequently needed to prevent the problem from happening again.

CausesBy Mayo Clinic staff

Testicular torsion

Testicular torsion occurs when the testicle rotates on the spermatic cord, which brings blood to the

testicle from the abdomen. If the testicle rotates several times, blood flow to it can be entirely blocked,

causing damage more quickly.

Most males who get testicular torsion have an inherited trait that allows the testicle to rotate freely

inside the scrotum. This inherited condition often affects both testicles. But not every male with the

trait will have testicular torsion.

What causes testicular torsion is unknown. Signs and symptoms of testicular torsion may follow:

Physical activity

An injury to the scrotum

Cold temperatures

Rapid growth of the testis during puberty

Sleep

Risk factorsBy Mayo Clinic staff

Age. Testicular torsion is most common between ages 12 and 16.

Previous testicular torsion. If you've had testicular pain that went away without treatment

(intermittent torsion and detorsion), it's likely to occur again. The more frequent the bouts of pain, the

likelier the testicle is to be permanently damaged.

Family history of testicular torsion. The condition may run in families.

ComplicationsBy Mayo Clinic staff

Testicular torsion can cause the following complications:

Damage to or death of the testicle. When testicular torsion is not treated for several hours, blocked

blood flow can cause permanent damage or death of the testicle. If the testicle is badly damaged, it

has to be surgically removed.

Inability to father children. In some cases, damage or loss of a testicle affects a man's ability to

father children.

Tests and diagnosisBy Mayo Clinic staff

Your doctor will ask you a number of questions to verify whether your signs and symptoms are

caused by testicular torsion or something else. Doctors often diagnose testicular torsion with just a

physical exam of your scrotum, testicles, abdomen and groin. Your doctor may also test your reflexes

by lightly rubbing or pinching the inside of your thigh on the affected side. Normally, this causes the

testicle to contract. This reflex may not occur if you have testicular torsion.

Sometimes medical tests are necessary to confirm a diagnosis or to help identify another cause for

your symptoms. These include:

Urine test to check for infection.

Scrotal ultrasound to check blood flow. Decreased blood flow to the testicle is a sign of testicular

torsion. But ultrasound doesn't always detect the reduced blood flow, so the test may not rule out

testicular torsion.

Surgery is sometimes necessary to determine whether your symptoms are caused by testicular

torsion or another condition.

If you've had pain for several hours and your physical exam suggests testicular torsion, you may be

taken directly to surgery without any additional testing. Delaying surgery might result in loss of the

testicle.

Treatments and drugsBy Mayo Clinic staff

Surgery is required to correct testicular torsion. In some cases, the doctor may be able to untwist the

testicle by pushing on the scrotum (manual detorsion), but you'll still need surgery to prevent torsion

from occurring again.

Surgery for testicular torsion is usually done under general anesthesia, which means you won't be

conscious. The surgery generally doesn't require a stay in the hospital. During surgery, your doctor

will:

Make a small cut in your scrotum

Untwist your spermatic cord, if necessary

Stitch one or usually both testicles to the inside of the scrotum to prevent rotation

The sooner the testicle is untwisted, the greater the chance it can be saved. The success rate is about

95 percent when treatment occurs within six hours, but declines steadily to about 20 percent after 24

hours.

Testicular torsion in newborns and infants

Testicular torsion may occur in newborns and infants, though it's rare. The infant's testicle may be

hard, swollen or a darker color. Ultrasound may not detect reduced blood flow to the infant's scrotum,

so surgery may be needed to confirm testicular torsion.

Treatment for testicular torsion in infants is controversial. If a boy is born with signs and symptoms of

testicular torsion, it may be too late for emergency surgery to help. In some cases, the doctor may

recommend a later, nonemergency surgery. But emergency surgery can sometimes save all or part of

the testicle and can prevent torsion in the infant's other testicle. Treating testicular torsion in infants

may prevent future problems with male hormone production and with fathering children.

PreventionBy Mayo Clinic staff

Having testicles that can rotate in the scrotum is a trait inherited by some males. If you have this trait,

the only way to prevent testicular torsion is surgery to attach both testicles to the inside of the

scrotum.

References1. Barthold JS. Abnormalities of the testes and scrotum and their surgical management. In: Wein AJ, et al. Campbell-

Walsh Urology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http://www.mdconsult.com/booksS/about.do?about=true&eid=4-u1.0-B978-1-4160-6911-9..C2009-1-60786-3--TOP&isbn=978-1-4160-6911-9&uniqId=314388803-2. Accessed Jan. 24, 2012.

2. Somani BK, et al. Testicular torsion. BMJ. 2010;341:c3213.

3. Cubillos J, et al. Familial testicular torsion. Journal of Urology. 2011;185:2469.

4. Tiemstra JD. Evaluation of scrotal masses. American Family Physician. 2008;78:1165.

5. Snyder HM, et al. In utero/neonatal torsion: Observation versus prompt exploration. Journal of Urology. 2010;183:1675.

6. Roth CC, et al. Salvage of bilateral asynchronous perinatal testicular torsion. Journal of Urology. 2011;185:2464.

7. Nippoldt TB (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 28, 2012.

DS01039March 7, 2012

© 1998-2013 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of

these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com,"

"EmbodyHealth," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for

Medical Education and Research.

http://www.healthline.com/health/testicular-torsion

What Is Torsion of the Testes?In men with torsion of the testes, the spermatic cord becomes twisted. This cord carries blood to the testicles.When the cord twists, it cuts off blood supply to the testicles. This causes severe pain. It can also permanently damage or destroy the testicles.Another name for this condition is testicular torsion. According to the American Urological Association (AUA), it is rare, affecting only about one in 4,000 young men (AUA).Torsion is most common in adolescent males. However, older men and infant boys can also be affected.

What Causes Torsion of the Testes?Most men who have testicular torsion are born with a predisposition to the condition. Normally, the testicles cannot move freely inside the scrotum. The surrounding tissue is strong and supportive. Men and boys who experience torsion sometimes have weakerconnective tissue in the scrotum. This is called a “bell clapper” deformity.If you have a bell clapper deformity, your testicles can move more easily in the scrotum. This movement increases the risk of the spermatic cord becoming twisted.Torsion of the testes can also occur after an injury to the groin. Rapid growth during puberty may also cause the condition.Testicular torsion usually occurs in only one testicle. Bilateral torsion is rare.

Symptoms of Testicular TorsionPain and swelling of the scrotal sac are the main symptoms of testicular torsion. The onset of pain may be quite sudden, and pain can be severe. Swelling may be limited to just one side, or it can span the entire scrotum. You may notice that one testicle is higher than the other. Some men also experience:

dizziness nausea vomiting lumps in the scrotal sac blood in the semen

Diagnosing Testicular TorsionA number of tests can be used to diagnose torsion. These include:

physical examination urine tests , which look for infection imaging of the scrotum

During a physical exam, your doctor will check your scrotum for swelling. He or she may also pinch the inside of your thigh. Normally this causes the testicles to contract. However, this reflex may disappear if you have torsion.

You might also receive an ultrasound on your scrotum. This shows blood flow to the testicles. If it is lower than normal, you may be suffering from torsion.

Treating Torsion of the TestesSurgical repair is usually required to treat testicular torsion. In rare cases, your doctor may be able to untwist the spermatic cord by hand. This procedure is called “manual detorsion.”

Surgical RepairSurgery is performed as quickly as possible to restore blood flow to the testicles. If blood flow is cut off for more than six hours, testicular tissue can die. The affected testicle would then need to be removed.Surgical detorsion is performed under general anesthesia. You will be asleep and unaware of the procedure. Your doctor will make a small incision in your scrotum and untwist the cord. Tiny sutures will be used to keep the testicle in place in the scrotum. This prevents rotation from occurring again. The surgeon then closes the incision with stitches.

Long-Term OutlookTesticular torsion surgery is highly effective if the condition is caught early. Ninety-five percent of patients make a full recovery when surgery is performed within six hours after symptoms appear (Mayo Clinic).Approximately 75 percent of patients require removal of the testicle when surgery is postponed for more than 12 hours (AUA).Removal of a testicle, called orchidectomy, can affect hormone production in infants. It may also affect future fertility by lowering sperm count.If your body begins to make anti-sperm antibodies because of torsion, this can also lower sperm motility.

http://www.patient.co.uk/doctor/torsion-of-the-testis-pro

Torsion of the TestisTorsion of the testis may more accurately be called torsion of the spermatic cord. It

causes occlusion of testicular blood vessels and, unless prompt action is taken, the

viability of the testis is compromised.

Epidemiology

Testicular torsion occurs in approximately one in 4,000 males under 25 years of age.

Its peak age range is 7-14 years.[1] A perinatal form has been identified, occurring

prenatally or in the first ten days of life.[2] The left side is more commonly affected

than the right.[3] Bilateral cases are rare.[4] There were 2,504 cases admitted to

hospitals in England in the year 2011-2012. The mean age of patients was 16 years.[5] Risk factors[6] A high insertion of the tunica vaginalis produces a 'bell-clapper testis' with a

horizontal lie rather high in the scrotum. This lie, with the long axis in the horizontal

rather than the vertical plain, is usually bilateral. There may be a genetic factor in

some cases of torsion.[7] 

Presentation[8][9]

Acute swelling of the scrotum in a boy indicates torsion of the testis until proven

otherwise. In approximately two thirds of patients, history and physical examination

are sufficient to make an accurate diagnosis.

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History There is typically sudden, severe pain in one testis. There may be lower abdominal pain and, in any boy presenting with abdominal

pain, the testes should be checked. It often comes on during sport or physical activity. There is quite often a history of previous, brief episodes of similar pain. This is

presumably torsion that corrected itself. There may be nausea and vomiting. Occasionally, the symptoms are milder and less acute. Easing pain is not necessarily a good sign of spontaneous resolution. Pain also

eases as necrosis sets in.ExaminationExamination is often helpful but normal findings should not preclude further investigation if clinical suspicion is high.[10]

There is usually reddening of the scrotal skin. There is a swollen, tender testis retracted upwards. Lifting the testis up over the symphysis increases pain, whereas in epididymitis

this usually relieves pain. In the early stages, the epididymis may be felt in an abnormal anterior rather

than typical posterior position but this depends upon the degree of torsion that may be from 180-720°. Later, gross swelling prevents this finding.

The testes on both sides are characteristically in the 'bell-clapper position' with a horizontal long axis.

If the torsion occurs prenatally, the baby is born with a firm, hard, non-transilluminable scrotal mass. There are no symptoms.The scrotal skin is usually fixed to the underlying necrotic testis.

Differential diagnosis[9]  Torsion of testicular or epididymal appendage:

This usually occurs in boys aged between 7 and 12 years. Systemic symptoms are rare. There is usually localised tenderness but only in the upper pole of the testis. Occasionally, the 'blue dot sign' is present in light-skinned boys (ie a tender

nodule with blue discoloration on the upper pole of the testis). Epididymitis, orchitis, epididymo-orchitis:

These conditions most commonly occur from the reflux of infected urine or from sexually acquired disease caused by gonococcus and Chlamydia spp. Hence, they tend to affect an older age group.

Hydrocele : Swelling is usually painless. The scrotum will transilluminate.

Incarcerated hernia: This may be diagnosed by careful examination of the inguinal canal.

Testicular tumour : Scrotal enlargement occurs more slowly. It is only rarely accompanied by pain. Typically, the normal slightly delicate

sensation of the testis is absent. Mumps :

There is swelling of the parotid glands in mumps. Mumps orchitis is rare before puberty.

Scrotal abscess: This has been mistaken for torsion in a premature infant.[11]

Investigations

Urinalysis may be helpful in borderline cases, to exclude urine infection and

epididymitis.

The most important investigation is ultrasound integrated with colour Doppler. A

very significant finding is the detection of presence/absence of intratesticular blood

flow for the early identification of testicular torsion.[12] 

Other useful modalities include dynamic contrast magnetic resonance imaging and

near-infrared imaging.[13] Scintigraphy and dynamic contrast-enhanced subtraction

magnetic resonance imaging (MRI) of the scrotum may be used when diagnosis

cannot be excluded from history, physical examination and ultrasound. However, if

clinical suspicion is high, surgical intervention should not be delayed for the sake of

further investigation.[14] 

Management[9][14]  It may be possible to reduce the torsion manually. The testes usually rotate in

different directions. The left testis rotates anticlockwise and the right testis clockwise in torsion. Hence, they need to be rotated in the opposite direction. If this relieves the pain, it is the correct direction. If it aggravates it, try the other direction.

If this is done, it should be verified by colour Doppler. If the manoeuvre is successful, orchidopexy must still be performed. This should be done in the immediate future, preferably before the patient leaves hospital.

If full manual reduction of torsion cannot be performed, or if there is doubt about the diagnosis and reason to suspect torsion, the scrotum must be explored.

In patients who present within 24 hours of torsion, the preferred option is exploration of the scrotum, detorsion and orchidopexy if the testis is viable.

After 24 hours there is controversy as to whether the testis should be removed or fixed, even if it shows some viability, as there is some evidence that orchiectomy is more likely to preserve the function and fertility of the ipsilateral testis.

If the testis is viable then orchidopexy is usually performed to prevent recurrence, although there is no consensus about this, as the evidence base is small.

Whether the affected testis is removed or conserved, the contralateral one should undergo orchidopexy, as the risk of recurrence on the other side is otherwise high.

A baby born with testicular torsion should have the affected testis removed (because it is always nonviable) and orchidopexy of the other side (because bilateral torsion is common).

Complications

Complications of an untreated or delayed torsion include infarction of the testicle

with subsequent atrophy, infection and cosmetic deformity.[15] There is some

evidence that retention of an injured testis can cause pathology in the contralateral

testis, abnormal semen analysis and decreased fertility.[14] 

Prognosis[14]  The extent and duration of torsion have a major influence on both the

immediate salvage rate and late testicular atrophy. Testicular salvage most likely occurs if the duration of torsion is less than six

hours.[16]  If it exists for 24 hours or more, testicular necrosis is usual. One study reported successful harvesting of semen from a subjectively dead

testicle, indicating that salvage and cryopreservation of semen should be attempted in all but the most hopeless cases.[17]

The absence of one testis has no significant effect on fertility, provided that the other functions normally. If both are affected by torsion, the outlook may be very bleak.

The absence of a testis may still have a significant psychological effect and so it is usual to implant a prosthesis if orchidectomy is required. This is usually delayed for six months to let inflammation subside and it is usually inserted via an inguinal incision.[18]

In men who have had a unilateral torsion, fertility is often impaired. This may be due

to subclinical torsion on both sides. Another possibility is that a pathological

condition predisposes to both abnormal spermatogenesis and torsion of the

spermatic cord. The 'bell-clapper' testis tends to be high and so temperature may be

higher than in glands that hang lower. There may also be an autoimmune

component as a result of injury to one testis.[19]

Prevention

Recurrent, intermittent pain, with a 'bell-clapper' testis, requires orchidopexy.[20] Delay has a considerable adverse effect on survival of the testis and late

presentation is a substantial problem. One study found that the main factor involved

in patients who have orchidectomies is length of symptoms and distance from

hospital; public education initiatives are likely to prove beneficial.[21]

Provide Feedback

Further reading & references

Rashed FK, Ghasemi B, Deldade Mogaddam H, et al ; The effect of erythropoietin on ischemia/reperfusion injury after testicular torsion/detorsion: a randomized experimental study. ISRN Urol. 2013 Mar 31;2013:351309. doi: 10.1155/2013/351309. Print 2013.

1. Seyed-Ali S ; Scrotal Pain, Merck Manual, 20092. Callewaert PR, Van Kerrebroeck P ; New insights into perinatal testicular torsion.

Eur J Pediatr. 2010 Jun;169(6):705-12. doi: 10.1007/s00431-009-1096-8. Epub 2009 Oct 25.

3. Fan R, Zhang J, Cheng L, et al ; Testicular and paratesticular pathology in the pediatric population: A 20 year experience at Riley hospital for children. Pathol Res Pract. 2013 Apr 28. pii: S0344-0338(13)00086-1. doi: 10.1016/j.prp.2013.04.002.

4. Baglaj M, Carachi R ; Neonatal bilateral testicular torsion: a plea for emergency exploration. J Urol. 2007 Jun;177(6):2296-9.

5. Hospital Episode Statistics, Admitted Patient Care - England, 2011-12 ; Health & Social Care Information Centre

6. Khan F, Muoka O, Watson GM ; Bell clapper testis, torsion, and detorsion: a case report. Case Rep Urol. 2011;2011:631970. doi: 10.1155/2011/631970. Epub 2011 Sep 19.

7. Shteynshlyuger A, Yu J ; Familial testicular torsion: A meta analysis suggests inheritance. J Pediatr Urol. 2012 Sep 24. pii: S1477-5131(12)00211-2. doi: 10.1016/j.jpurol.2012.08.002.

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Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of

medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty

as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of

medical conditions. For details see our conditions.

Original Author: Dr Laurence Knott

Current Version: Dr Laurence Knott

Peer Reviewer: Dr Helen Huins

Last Checked: 02/07/2013 Document ID: 676  Version: 23 © EMIS

http://www.nlm.nih.gov/medlineplus/ency/article/000517.htm

Testicular torsion

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Testicular torsion is the twisting of the spermatic cord, which cuts off the blood supply to the testicle

and surrounding structures within the scrotum.

Causes

Some men may be predisposed to testicular torsion as a result of inadequate connective tissue within

the scrotum. However, the condition can result from trauma to the scrotum, particularly if significant

swelling occurs. It may also occur after strenuous exercise or may not have an obvious cause.

The condition is more common during the first year of life and at the beginning of adolescence

(puberty), but may happen in older men.

Symptoms

Sudden onset of severe pain in one testicle, with or without a previous predisposing event

Swelling within one side of the scrotum (scrotal swelling)

Nausea or vomiting

Lightheadedness

Additional symptoms that may be associated with this disease:

Testicle lump

Blood in the semen

Exams and Tests

The health care provider will examine you. This may show:

Extreme tenderness and swelling in the testicle area

The testicle on the affected side is higher

Doppler ultrasound of the testicle can show blood flow. There will be no blood flow through the area if

you have complete torsion. It may be reduced if you have a partial torsion of the testicle.

Treatment

Surgery is usually required and should be performed as soon as possible after symptoms begin. If

surgery is performed within 6 hours, most testicles can be saved.

During surgery, the testicle on the other (unaffected) side is usually also anchored as a preventive

measure. This is because the unaffected testicle is at risk of testicular torsion in the future.

Outlook (Prognosis)

If the condition is diagnosed quickly and immediately corrected, the testicle may continue to function

properly. After 6 hours of torsion (impaired blood flow), the likelihood that the testicle will need to be

removed increases. However, even with fewer than 6 hours of torsion, the testicle may lose its ability

to function.

Possible Complications

If the blood supply is cut off to the testicle for a prolonged period of time, it may atrophy (shrink) and

need to be surgically removed. Atrophy of the testicle may occur days to months after the torsion has

been corrected. Severe infection of the testicle and scrotum is also possible if the blood flow is

restricted for a prolonged period.

When to Contact a Medical Professional

Go to the emergency room or call the local emergency number (such as 911) if testicular torsion

symptoms occur.

Prevention

Use precautions to avoid trauma to the scrotum. Many cases are not preventable.

Alternative Names

Torsion of the testis; Testicular ischemia; Testicular twisting

References

Elder JS. Disorders and anomalies of the scrotal contents. In: Kliegman RM, Behrman RE, Jenson

HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier;

2011:chap 539.

Ban KM, Easter JS. Selected urologic problems. In: Marx JA, Hockberger RS, Walls RM, et al,

eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby

Elsevier; 2009:chap 97.

Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care. 2010;37:613-626.

Barthold JS. Abnormalities of the testes and scrotum and their surgical management.In: Wein AJ,

ed.Campbell-Walsh Urology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 132. 

Update Date: 9/24/2012

Updated by: Linda J. Vorvick, MD, Medical Director and Director of Didactic Curriculum, MEDEX

Northwest Division of Physician Assistant Studies, Department of Family Medicine, UW Medicine,

School of Medicine, University of Washington. Louis S. Liou, MD, PhD, Chief of Urology, Cambridge

Health Alliance, Visiting Assistant Professor of Surgery, Harvard Medical School. Also reviewed by

David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.

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