ANOTHER LOOK AT TORSION OF TESTIS JAMES
D. WILLIAMS,
NORMAN
B. HODGSON,
M.D. M.D.
From the Department of Urology, Milwaukee Children’s Medical College of Wisconsin, Milwaukee, Wisconsin
Hospital,
ABSTRACT -A retrospective review was done of all patients who had been discharged with a diagnosis of testicular torsion from 1967 to 1977. Multiple staff physicians were involved at the Milwaukee Children’s Hospital. Incidence, age, presenting symptoms, and testicular survival were compared with previous reports in the literature. A 69 per cent testicular survival from torsion of the testis is a marked improvement over other series. Some suggestions fm other diagnostic and therapeutic aids are mentioned.
Torsion of the testis is a urologic emergency which requires early diagnosis and prompt surgical treatment for testicular survival. The condition was first described in 1840 by Delasiave, a Frenchman, while exploring a condition he thought preoperatively to be a strangulated hernia.’ Numerous articles have been written since emphasizing the necessity of maintaining a high index of suspicion of torsion when evaluating an acute condition of the scrotum. Nevertheless, reports of a high incidence of orchiectomy persist. A review of the approximately 500 cases reported until 1963 revealed that 90 per cent of the patients with torsion of the testis lose the testis to orchiectomy (80 per cent) or by subsequent atrophy (10 per cent).2 Barker and Raper2 presented an additional 38 cases of torsion of the testis with a 58 per cent loss of the testes. In 1966, Allan and Brown3 reviewed 58 cases with an 80 per cent over-all testes loss. In 1975 Bourne and Lee4 reviewed 28 cases, with 64 per cent being lost to torsion. A review was done of all the charts of patients with discharge diagnoses of testicular torsion at the Milwaukee Children’s Hospital from 1967 to 1977. This retrospective study of 32 cases was done with emphasis on the incidence, age, presenting symptoms, and testicular survival.
36
Clinical Findings The presentation of 32 cases in a ten-year period is consistent with the reported incidence of 3 or 4 patients per year in a large general hospital.5 This rejects earlier literature suggestions that testicular torsion is rare. The ages of the patients ranged from six weeks to fifteen years, with a mean age of 10.2 years reflecting the pediatric age group treated at a pediatric hospital (Fig. 1). Other authors 8
6
NUMBER OF PATIENTS
4
I
t
0
10
5 AGE
MEAN
AGE=10.2
15
2b
IN YEARS
YEARS
Age distribution in 32 cases of torsion of testis (Milwaukee Children’s Hospital - 19671977). FIGURE
1.
UROLOGY
/ JULY 1979 I
VOLUME
XIV, NUMBER
1
have observed a similar distribution of patient ages with a distinct peak incidence at puberty.2*3a5,6 This contrasts clearly with acute epididymitis which is more common in the older age groups as reported by several authors.2*3 Scrotal pain and swelling were the predominant presenting symptoms, with each occurring in 30 of the 32 patients. Four patients had experienced identical symptoms previously which suggested intermittent torsion. Six patients had nausea or vomiting, and 2 patients had abdominal pain. Kaplan and King7 found that 10 per cent of their 34 patients with torsion of the testis had no pain, which is certainly of Our review relied on the clinical importance. original examiner recording such a history, therefore, it may reflect such incomplete documentation. All 32 patients had torsion of a scrotal testis, 4 of which were documented to be extravaginal torsion. Twenty-two of the 32 cases occurred on the left side, a disparity which is true in other series. A review of the literature by Skoglund, McRoberts, and Ragde in 19705 revealed that 61 per cent of 472 recorded cases occurred on the left side.
TABLE I. Torsion of testis
Duration of Symptoms O-12 hours 12-24 hours >24 hours TOTALS
Treatment Orchiopexy
(32 cases) Orchiectomy
20 2
0
2
-7
24*
8
1
*Twocaw~resulted in atrophy for a 69 per cent testicular survival.
Multiple staff physicians were involved in the diagnosis and treatment of the 32 patients. The diagnosis of torsion was confirmed by surgical exploration of all 32 patients (Table I). Thirty patients had bilateral explorations with contralateral orchiopexy. Eight patients were judged to have arterial ischemia, and an orchiectomy was performed. All patients having an orchiectomy as treatment had experienced symptoms for more than twelve hours. Two patients had orchiopexies performed, but were observed to have testicular atrophy at follow-up. Therefore, 22 of 32 testes were salvaged for a 69 per cent survival reflecting the rate of earlier diagnosis and treatment.
UROLOGY
/ JULY1979 / VOLUMEXIV, NUMBER 1
Comment The best known anatomic variant allowing torsion is the complete investment of the testis, epididymis, and cord by the tunica vaginalis, referred to as the bell-clapper deformity. Parker and Robinson* describe other variations of tunica vaginalis investment seen in 21 cases and record that 33 per cent of patients had an elongated mesorchium as the site of torsion. It was not possible to determine the representative anatomy associated with torsion in our review due to the lack of original documentation Ormond demonstrated in 1938 that the first effect of torsion is obstruction of venous return; then, as twisting persisted, thrombosis of the veins followed by arterial thrombosis occurs.% The degree of obstruction is a function of the If rotation is incomplete, degree of rotation. edema and congestion occur, initially in the more distensible epididymis. Necrosis occurs with complete venous obstruction, and infarction develops promptly with arterial thrombosis. Smith9 demonstrated in dogs that complete arterial ischemia for six hours eliminated all spermatogenic cells, and the Leydig cells were severely damaged after eight hours. This emphasizes the need for early derotation of the twisted testis. Delay in treatment of testicular torsion may occasionally be due to adolescent shyness of his changing physical image. However, the physician is at fault when he confuses torsion and epididymitis and pursues conservative management. The problem in treatments is the choice between orchiopexy and orchiectomy. When the acute scrotal condition is associated with a normal urinalysis, one should proceed directly to exploration. Conjunctive diagnostic procedures are available. Use of the Doppler evaluation has been recommended but has not found widespread favor. Ultrasound has been suggested but is unreliable. Preoperative scanning is in vogue, but this is sometimes a hedge and should not be used as a nonoperative excuse by insensitive observers. It is available at Milwaukee Children’s Hospital twenty-four hours a day, but we doubt this will become universal. Various intraoperative diagnostic tools are available to assess arterial thrombosis. Atallah, Mazzarino, and Horton” correlated the biopsyproved testis viability with improved perfusion by comparing pre- and postoperative testicular
37
scanning. Intraoperative testicular scanning may, therefore, provide confirmation of testis viability, but needs further investigation. Schneider, Kendall, and Karafin12 demonstrated a positive correlation to gross and microscopic viability using intraoperatively 5 per cent fluorescein sodium injected intravenously. The aqueous dye in viable tissue is strongly fluorescent under a Wood’s light. Other intraoperative aids to the surgeon include the Doppler ultrasonic flowmeter and the creation of serial incisions of the tunica albuginea to visualize arterial bleeding. If the testicle is viable, fixation of the involved testis to the dartos using two or three sutures is essential, since several cases of torsion have been reported after orchiopexy using a single suture. 4~13 When intravaginal torsion exists, contralateral exploration and orchiopexy are essential because of the high incidence of bilaterality of the anatomic deformity. l4 Conclusion A review of 32 patients treated for testicular torsion at the Milwaukee Children’s Hospital over a ten-year period reveals the series to be comparable in incidence and age to previous reports in the literature. The most predominant presenting symptoms were scrotal pain and swelling. A 69 per cent testicular salvage rate was obtained due to early diagnosis and treatment. This is an improvement from previous
38
reports in the literature and reflects increased physician awareness of this clinical entity. 700 North Water Street Milwaukee. Wisconsin 53202 (DR. HODGSON) ACKNOWLEDGMENTS. for assistance in preparing
To K. Lath this material.
and
S
Koscielniak
References 1. Burton JA: Atrophy following testicular torsion, Br. J. Surg. 59: 422 (1972). 2. Barker K, and Raper FP: Torsion of the testis, Br. J. Urol. 36: 35 (1964). 3. Allan WR, and Brown RB: Torsion of the testis: a review of 58 cases, Br. Med. J. 1: 1396 (1966). 4. Boume HL, and Lee RE: Torsion of spermatic cord and testicular appendages, Urology 5: 73 (1975). 5. Skoglund RW, McRoberts JW, and Ragde H: Torsion of the spermatic cord: a review of the literature and an analysis of 70 new cases, J. Ural. 104:604 (1970). 6. Wright JE: Torsion of the testis, Br. J. Ural. 64: 274 (1977). 7. Kaplan GW, and King LR: Acute scrotal swelling in children, J. Ural. 164: 219 (1970)). 8. Parker RM, and Robinson JR: Anatomy and diagnosis of torsion of the testicle, ibid. 106:243 (1971). 9. Smith GI: Cellular changes from graded testicular ischemia, ibid. 73: 355 (1955). 10. Naddl NS, Gitter MH, Hahn LC, and Vernon AR: Preoperative diagnosis of testicular torsion, Urology 1: 478 (1973)). 11. Atallah MW, Mazzarino AF, and Horton BF: Testicular scan, diagnosis and follow-up for torsion of testis, J. Ural. 118: 120 (1977). 12. Schneider HC, Kendall AR, and Karatin L: Fluorescence of testicle, Urology 5: 133 (lQ75). 13. Johenning PW: Torsion of the previously operated testicle, J. Ural. 110: 221 (1973). 14. Lyon RP: Torsion of the testicle in childhood, J.A.M.A. 178: 110 (1961).
UROLOGY
/
JULY 1979
I
VOLUME
XIV, NUMBER
1
D. WILLIAMS,
NORMAN
B. HODGSON,
M.D. M.D.
From the Department of Urology, Milwaukee Children’s Medical College of Wisconsin, Milwaukee, Wisconsin
Hospital,
ABSTRACT -A retrospective review was done of all patients who had been discharged with a diagnosis of testicular torsion from 1967 to 1977. Multiple staff physicians were involved at the Milwaukee Children’s Hospital. Incidence, age, presenting symptoms, and testicular survival were compared with previous reports in the literature. A 69 per cent testicular survival from torsion of the testis is a marked improvement over other series. Some suggestions fm other diagnostic and therapeutic aids are mentioned.
Torsion of the testis is a urologic emergency which requires early diagnosis and prompt surgical treatment for testicular survival. The condition was first described in 1840 by Delasiave, a Frenchman, while exploring a condition he thought preoperatively to be a strangulated hernia.’ Numerous articles have been written since emphasizing the necessity of maintaining a high index of suspicion of torsion when evaluating an acute condition of the scrotum. Nevertheless, reports of a high incidence of orchiectomy persist. A review of the approximately 500 cases reported until 1963 revealed that 90 per cent of the patients with torsion of the testis lose the testis to orchiectomy (80 per cent) or by subsequent atrophy (10 per cent).2 Barker and Raper2 presented an additional 38 cases of torsion of the testis with a 58 per cent loss of the testes. In 1966, Allan and Brown3 reviewed 58 cases with an 80 per cent over-all testes loss. In 1975 Bourne and Lee4 reviewed 28 cases, with 64 per cent being lost to torsion. A review was done of all the charts of patients with discharge diagnoses of testicular torsion at the Milwaukee Children’s Hospital from 1967 to 1977. This retrospective study of 32 cases was done with emphasis on the incidence, age, presenting symptoms, and testicular survival.
36
Clinical Findings The presentation of 32 cases in a ten-year period is consistent with the reported incidence of 3 or 4 patients per year in a large general hospital.5 This rejects earlier literature suggestions that testicular torsion is rare. The ages of the patients ranged from six weeks to fifteen years, with a mean age of 10.2 years reflecting the pediatric age group treated at a pediatric hospital (Fig. 1). Other authors 8
6
NUMBER OF PATIENTS
4
I
t
0
10
5 AGE
MEAN
AGE=10.2
15
2b
IN YEARS
YEARS
Age distribution in 32 cases of torsion of testis (Milwaukee Children’s Hospital - 19671977). FIGURE
1.
UROLOGY
/ JULY 1979 I
VOLUME
XIV, NUMBER
1
have observed a similar distribution of patient ages with a distinct peak incidence at puberty.2*3a5,6 This contrasts clearly with acute epididymitis which is more common in the older age groups as reported by several authors.2*3 Scrotal pain and swelling were the predominant presenting symptoms, with each occurring in 30 of the 32 patients. Four patients had experienced identical symptoms previously which suggested intermittent torsion. Six patients had nausea or vomiting, and 2 patients had abdominal pain. Kaplan and King7 found that 10 per cent of their 34 patients with torsion of the testis had no pain, which is certainly of Our review relied on the clinical importance. original examiner recording such a history, therefore, it may reflect such incomplete documentation. All 32 patients had torsion of a scrotal testis, 4 of which were documented to be extravaginal torsion. Twenty-two of the 32 cases occurred on the left side, a disparity which is true in other series. A review of the literature by Skoglund, McRoberts, and Ragde in 19705 revealed that 61 per cent of 472 recorded cases occurred on the left side.
TABLE I. Torsion of testis
Duration of Symptoms O-12 hours 12-24 hours >24 hours TOTALS
Treatment Orchiopexy
(32 cases) Orchiectomy
20 2
0
2
-7
24*
8
1
*Twocaw~resulted in atrophy for a 69 per cent testicular survival.
Multiple staff physicians were involved in the diagnosis and treatment of the 32 patients. The diagnosis of torsion was confirmed by surgical exploration of all 32 patients (Table I). Thirty patients had bilateral explorations with contralateral orchiopexy. Eight patients were judged to have arterial ischemia, and an orchiectomy was performed. All patients having an orchiectomy as treatment had experienced symptoms for more than twelve hours. Two patients had orchiopexies performed, but were observed to have testicular atrophy at follow-up. Therefore, 22 of 32 testes were salvaged for a 69 per cent survival reflecting the rate of earlier diagnosis and treatment.
UROLOGY
/ JULY1979 / VOLUMEXIV, NUMBER 1
Comment The best known anatomic variant allowing torsion is the complete investment of the testis, epididymis, and cord by the tunica vaginalis, referred to as the bell-clapper deformity. Parker and Robinson* describe other variations of tunica vaginalis investment seen in 21 cases and record that 33 per cent of patients had an elongated mesorchium as the site of torsion. It was not possible to determine the representative anatomy associated with torsion in our review due to the lack of original documentation Ormond demonstrated in 1938 that the first effect of torsion is obstruction of venous return; then, as twisting persisted, thrombosis of the veins followed by arterial thrombosis occurs.% The degree of obstruction is a function of the If rotation is incomplete, degree of rotation. edema and congestion occur, initially in the more distensible epididymis. Necrosis occurs with complete venous obstruction, and infarction develops promptly with arterial thrombosis. Smith9 demonstrated in dogs that complete arterial ischemia for six hours eliminated all spermatogenic cells, and the Leydig cells were severely damaged after eight hours. This emphasizes the need for early derotation of the twisted testis. Delay in treatment of testicular torsion may occasionally be due to adolescent shyness of his changing physical image. However, the physician is at fault when he confuses torsion and epididymitis and pursues conservative management. The problem in treatments is the choice between orchiopexy and orchiectomy. When the acute scrotal condition is associated with a normal urinalysis, one should proceed directly to exploration. Conjunctive diagnostic procedures are available. Use of the Doppler evaluation has been recommended but has not found widespread favor. Ultrasound has been suggested but is unreliable. Preoperative scanning is in vogue, but this is sometimes a hedge and should not be used as a nonoperative excuse by insensitive observers. It is available at Milwaukee Children’s Hospital twenty-four hours a day, but we doubt this will become universal. Various intraoperative diagnostic tools are available to assess arterial thrombosis. Atallah, Mazzarino, and Horton” correlated the biopsyproved testis viability with improved perfusion by comparing pre- and postoperative testicular
37
scanning. Intraoperative testicular scanning may, therefore, provide confirmation of testis viability, but needs further investigation. Schneider, Kendall, and Karafin12 demonstrated a positive correlation to gross and microscopic viability using intraoperatively 5 per cent fluorescein sodium injected intravenously. The aqueous dye in viable tissue is strongly fluorescent under a Wood’s light. Other intraoperative aids to the surgeon include the Doppler ultrasonic flowmeter and the creation of serial incisions of the tunica albuginea to visualize arterial bleeding. If the testicle is viable, fixation of the involved testis to the dartos using two or three sutures is essential, since several cases of torsion have been reported after orchiopexy using a single suture. 4~13 When intravaginal torsion exists, contralateral exploration and orchiopexy are essential because of the high incidence of bilaterality of the anatomic deformity. l4 Conclusion A review of 32 patients treated for testicular torsion at the Milwaukee Children’s Hospital over a ten-year period reveals the series to be comparable in incidence and age to previous reports in the literature. The most predominant presenting symptoms were scrotal pain and swelling. A 69 per cent testicular salvage rate was obtained due to early diagnosis and treatment. This is an improvement from previous
38
reports in the literature and reflects increased physician awareness of this clinical entity. 700 North Water Street Milwaukee. Wisconsin 53202 (DR. HODGSON) ACKNOWLEDGMENTS. for assistance in preparing
To K. Lath this material.
and
S
Koscielniak
References 1. Burton JA: Atrophy following testicular torsion, Br. J. Surg. 59: 422 (1972). 2. Barker K, and Raper FP: Torsion of the testis, Br. J. Urol. 36: 35 (1964). 3. Allan WR, and Brown RB: Torsion of the testis: a review of 58 cases, Br. Med. J. 1: 1396 (1966). 4. Boume HL, and Lee RE: Torsion of spermatic cord and testicular appendages, Urology 5: 73 (1975). 5. Skoglund RW, McRoberts JW, and Ragde H: Torsion of the spermatic cord: a review of the literature and an analysis of 70 new cases, J. Ural. 104:604 (1970). 6. Wright JE: Torsion of the testis, Br. J. Ural. 64: 274 (1977). 7. Kaplan GW, and King LR: Acute scrotal swelling in children, J. Ural. 164: 219 (1970)). 8. Parker RM, and Robinson JR: Anatomy and diagnosis of torsion of the testicle, ibid. 106:243 (1971). 9. Smith GI: Cellular changes from graded testicular ischemia, ibid. 73: 355 (1955). 10. Naddl NS, Gitter MH, Hahn LC, and Vernon AR: Preoperative diagnosis of testicular torsion, Urology 1: 478 (1973)). 11. Atallah MW, Mazzarino AF, and Horton BF: Testicular scan, diagnosis and follow-up for torsion of testis, J. Ural. 118: 120 (1977). 12. Schneider HC, Kendall AR, and Karatin L: Fluorescence of testicle, Urology 5: 133 (lQ75). 13. Johenning PW: Torsion of the previously operated testicle, J. Ural. 110: 221 (1973). 14. Lyon RP: Torsion of the testicle in childhood, J.A.M.A. 178: 110 (1961).
UROLOGY
/
JULY 1979
I
VOLUME
XIV, NUMBER
1
