Testicular torsion

Among the main factors that can cause the development of testicular torsion, the following are noted:

• Pathological testicular motility ^[5] . Underdevelopment of the Gunter ligament (which normally fixes the testicle to the bottom of the scrotum ^[6] ) or various intrauterine disorders of the formation of the vaginal process of the peritoneum ^[7] can lead to it: the development of mesorchia (the mesentery of the testicle, which normally fixes it to the walls of the scrotum) is impaired , and the testicle acquires additional mobility in the form of a “bell tongue”.
• Sharp contractions of the scrotum and the muscle that lifts the testicle (which is possible with injuries, sudden movements, sudden tension of the abdominal muscles, masturbation, stubborn cough) ^{[8] [9]} . However, the testicle can often be twisted in a dream ^[6] . One of the predisposing factors for the development of testicular torsion is also wearing tight clothing ^[8] .

Most often, this pathology occurs in early childhood and in the puberty ^{[5] [10]} ; about 65% of cases occur at the age of 12-18 years ^[11] . The frequency of occurrence in males under the age of 25 years varies from 1 in 4000 to 1 in 25,000 ^{[7] [10] [12]} . However, occasionally testicular torsion can be observed at a more mature age, including in the age period of 60–70 years ^[13] . There is evidence that testicular torsion can occur before birth (in the prenatal period of development), which can lead to the birth of a boy with monorchism (lack of one testicle) ^[14] .

Ceteris paribus, a larger testicle (its large size can be caused by individual characteristics or a developing tumor) is more prone to torsion ^[12] . The testicle often twists along its vertical axis from the outside inward ^{[6] [8]} . The degree of severity of the torsion is different (usually - about 80-180 ^[15] or 180-360 degrees ^[16] ); however, cases of testicular torsion are also described at 1080 degrees ^{[6] [16]} .

In some cases, the so-called habitual testicular torsion ^[5] (or partial torsion ^[16] ) is observed, in which short-term symptoms of torsion spontaneously disappear. Patients with a similar pathology belong to the high-risk group for the development of complete torsion ^[16] and, as a rule, they are shown surgical treatment (bilateral orchipexy ), which almost always leads to the complete disappearance of all symptoms ^[17] .

The following three types of testicular torsion are distinguished ^{[6] [18]} :

• Extravaginal form (extravaginal torsion), in which the testicle is twisted together with its vaginal membrane above the attachment of the parietal leaf of the vaginal membrane. This form is more common in children under the age of one year ^[9] or in prenatal development, which leads to congenital testicular necrosis, requiring surgical removal ^[19] .
• An intravaginal form in which the testicle twists inside the part of the spermatic cord that is in the cavity of the vaginal membrane of the testicle; the supravaginal part of the spermatic cord is not changed. It is more common at the age of 10–16 years, which is associated with a rapid increase in the size of the testis at this age ^[16] .
• Torsion of the testis on the mesentery of the appendage , in which the epididymis is not changed, and only those vessels that pass to the testicle along the mesentery of the appendage are squeezed. This option is possible only with a pronounced separation of the testis and appendage ^[16] .

With any form of torsion, blood circulation in the testicle and its appendage is sharply disturbed, ischemic changes are observed in the gland, the severity of which strongly depends on the duration and degree of torsion, as well as on the length of the spermatic cord (with a shorter cord, the degree of destructive changes in the testicle will be greater) . In most cases, if untreated, six to eight hours after the development of torsion, irreversible necrotic changes develop in the testicle (sometimes a short-term torsion can lead only to testicular atrophy ) ^[20] .

Probable complications of testicular torsion include:

• Testicular necrosis and gangrene
• Scrotal abscess , scrotal gangrene ( Fournier gangrene )
• Chronic epididymitis

The most pronounced symptom of testicular torsion is sudden and sharp pain (both in the scrotum and in the groin and lower abdomen) ^[10] . Often (especially in young children), nausea and vomiting are observed ^[10] . Testicular testicular torsion is more often located above its usual position. Locally, redness of the skin and an increase in its temperature can be observed. Local symptoms can often be scanty, while general symptoms (abdominal pain, vomiting, fever, dyspeptic disorders) prevail. Sometimes an additional manifestation of testicular torsion may be acute urinary retention . The testicle itself usually increases in size, with palpation its compacted consistency and soreness are determined ^{[21] [22]} .

In the absence of timely treatment after 18-24 hours, the pain often wanes, but local ( edema , hyperemia ) and general symptoms ( fever , intoxication, usually noticeable only in children) continue to increase ^[23] . In some cases (especially in infants), a collaptoid state may develop.

Most often, differential diagnosis of testicular torsion should be performed with orchitis (testicular torsion has a sharper onset ^[21] ) and epididymitis (the differential sign is that when the scrotum is raised, the pain with epididymitis often decreases, and with torsion, it usually does not change or even intensifies) ^{[21] [24]} ; with torsion of the testicle more often than in inflammatory processes, the cremaster reflex ^[10] weakens or disappears altogether, trauma of the testicle, torsion of the Morgagni hydatide (see below); less often - with a restrained inguinal hernia , dropsy of the testicle , Quincke's edema .

Laboratory tests of blood and urine in most cases do not allow confidently confirm the diagnosis of torsion or exclude diseases with similar symptoms. The most indicative method of instrumental diagnostics for suspected testicular torsion is Doppler ultrasound , which can detect circulatory disorders in the testicle ^{[10] [12] [25]} . An even more indicative (but also much less accessible ^[21] ) method is dynamic testicular scintigraphy using technetium acid preparations enriched in the ^99m Tc isotope ^[26] (for example, ^99m Tc sodium pertechnetate ^[27] ). In some cases, endoscopic diagnostic methods can also be used ^[23] .

In doubtful and urgent cases, as well as inaccessibility or inconclusive results of the use of instrumental methods, a diagnostic operation may be used, consisting in the dissection of the scrotum and lower part of the inguinal canal with the revision of the testicle ^[25] .

In the early stages of testicular torsion, a conservative treatment is possible, consisting in a bloodless (closed) detorsion (turn, untwisting) of the testicle. The testicle is grabbed with fingers through the skin of the scrotum and, trying to leave the scrotum wall motionless, turn it outward (towards the thigh), while slightly pulling the testicle down, repeating this manipulation several times ^[28] . With successful detorsion, the pain syndrome disappears or significantly decreases, and the testicle itself somewhat falls down to the bottom of the scrotum ^{[29] [30]} . Even with successful closed detorsion, the patient is shown an urgent operation to fix the testicle in order to prevent relapse (successfully performed before the operation, detorsion in this case improves the results of surgical treatment). The exact frequency of successful bloodless detrusions is unknown due to the relative rarity of the pathology (however, it is most likely not too high: according to some estimates, only about 3% ^[31] ). If it is impossible to perform an emergency operation after closed detorsion for one reason or another, the use of drugs that improve microcirculation ( trental , aminophylline , etc.), as well as novocaine blockade of the spermatic cord, is indicated ^[32] .

In case of failed closed detorsion (as well as in the relatively late stages of testicular torsion), the patient is shown to undergo emergency surgery: after access to the testicle (in newborns and infants, inguinal access is more often used, in older children and adults - an incision on the front surface of the scrotum ^[33] ) carry out its audit and untwisting (detorsion), after which the testicle is fixed to the bottom and septum of the scrotum. In cases where the state of the testicle seems doubtful, the testicle is heated with a warm isotonic solution for 20-25 minutes, papaverine , a novocaine mixture with heparin, is introduced into the spermatic cord. With obvious signs of testicular necrosis , an orchiectomy is performed ^[32] .

An exceptionally conservative treatment of testicular torsion is fraught with the appearance of sperm antibodies in the patient's body (due to violation of the hematotesticular barrier ), damage to the second testicle, and infertility ^[9] . In order to reduce the likelihood of such complications, all patients in the postoperative period are prescribed aspirin and heparin ; in some cases, corticosteroids ^[34] .

Testicular torsion refers to urgent (urgent) conditions: in case of developed testicular torsion, irreversible ischemic changes in the testicle usually develop within 6 hours ^[20] , and therefore this pathology requires urgent treatment. With timely intervention, the prognosis is favorable ^[34] . According to some estimates, testicular detorsion, performed within six hours from the onset of pathology, allows the testicle to be preserved in 90% of cases; after 12 hours from the onset of torsion, a positive result is achieved only in 50% of cases; after 24 hours, it is achievable only in 10% of cases ^[12] ; later, the testis is practically nonviable ^[31] .

Torsions of testicular and appendage hydatides also have a similar clinical picture, pathogenesis, and treatment principles (the so-called Morgagni hydatides are rudimentary processes, testicle and appendage pendants, which are the remnants of the paramesonephric duct ). Torsion of Morgagni hydatides, as a rule, is characterized by a more erased and "mild" course of the disease and relatively less frequent complications (compared with torsion of the testicle). Diagnosis of this pathology is rather difficult, the final diagnosis is often made only intraoperatively ^[35] .

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• Photos of the twisted testicle (before, during, and at the end of a successful operation) (Retrieved June 30, 2015)