Scandinavian Journal of Urology and Nephrology

ISSN: 0036-5599 (Print) 1651-2065 (Online) Journal homepage: http://www.tandfonline.com/loi/isju19

Torsion of the Testisa Lisa Andersen & Peer A. Wille-Jørgensen To cite this article: Lisa Andersen & Peer A. Wille-Jørgensen (1990) Torsion of the Testisa, Scandinavian Journal of Urology and Nephrology, 24:2, 91-93, DOI: 10.3109/00365599009180370 To link to this article: http://dx.doi.org/10.3109/00365599009180370

Published online: 15 Feb 2010.

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Date: 16 March 2016, At: 13:33

Scand J Urol Nephrol 24: 91-93, 1990

TORSION OF THE TESTIS A 5 - y ~ a Material r

Lisa Andersen and Peer A . Wille-J@rgensen From the Depurtment of Surgeuq, RosXilde Coirnty Hospital, Drnmurk

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(Submitted for publication March 10, 1989)

Abstract. During a 5-year period I 1 1 patients were operated for suspected torsion of the testis. In 64 patients with an age range from 2 months to 46 years acute torsion was found. Eleven testes were gangrenous. In four patients the affected testis was undescended and in four other the contralateral testis was undescended. Indications for explorative surgery on the acute scrotum should be wide even if operation has been previously performed.

Key words: testicular torsion, undescended testis.

Torsion of the testis is recognized and operated more frequently now than previously. However, the condition is still misdiagnosed or the treatment delayed resulting in loss of function of the testis (1, 3, 6, 7 , 9, 12). The first case of testicular torsion was reported by Delasiauve in 1840 (2) and involved an undescended testis. Undescended testes undergo torsion ten times as often as normal descended testes (15). Torsion of the undescended testis has been associated with neuromuscular diseases ( 5 , 7, 10). The aim of this study has been to evaluate the findings in patients operated on suspicion of torsion of the testis. MATERIAL AND METHODS All records of patients discharged with the diagnosis torsion of the testis or testicular appendages or operated under suspicion of above mentioned diagnoses at Roskilde County Hospital from 1980-1985 have been reviewed. Age, physical development, position and state of the testis, time from onset of symptoms to treatment, diagnosis, and treatment were registered. For statistics the Chi-square test was used.

RESULTS One hundred and fifteen patients fulfilled the inclusion criteria. Of these, 3 patients did not undergo

surgery and were excluded from the material. One patient-file was missing. The intraoperative diagnoses of the 11 1 patients are listed in Table I. Emergency operations were performed in 99 cases and in 12 cases elective operation was performed because of a story of recurrent attacks of testicular pains. In Fig. 1 the diagnosis according to age are listed. The chance of finding torsion of the testis at emergency surgery was significantly higher in the group of patients between 11 and 20 years of age (Chisquare= 10.91, df=4, p=0.03), but also in the group of patients between the age of 21 and 30 torsion of testis was the predominant diagnosis. Torsion of testicular appendages was not seen in patients above 20 years of age. In 38 patients the right testis was affected and in 35 the left. Three patients had had symptoms from both testes. In 11 cases the testis was found gangrenous and orchiectomy was performed. In these 11 cases the duration of symptoms was longer than 24 hours except from a 2 months old baby with only 10 hours symptoms. Preservation of the testis was possible in 53 of the 64 cases of acute torsion (83 %, 95% confidence interval 71-91). In one patient with acute torsion, bilateral fixation had been performed 6 months earlier, apparently unsuccessfully. Nine of the 64 patients (14%) operated urgently for torsion revealed an undescended testis, either on the affected or the contralateral side. Four patients had torsion of an undescended testis. In three of these the contralateral testis was normally placed, but in one with a gangrenous testis the opposite testis was placed intraabdominally. In other four patients with normally placed torquated testes, the contralateral testes were undescended, 3 in the inguinal canal and one could not be found. In one patient the affected testis was operated for Scand

J Uro/ N e p h r d 24

92 50

L . Andersen und P . A . Wille-J@rgensen Jfnber

-

40

Torsion of testis

Recurrent

30

torsion

Torsion of appendages

20

I Other diagnosis

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10

0

dl >40

0- 10

11-20

2 1-30

3 1-40

Age in years Fig. 1 . Distribution of age according to diagnosis in 11 1 patients operated for suspicion of testicular torsion.

maldescensus 6 months before the acute attack. We found no patients with known neuromuscular disease.

DISCUSSION Nearly all torsions of testes are intravaginal except for torsion in newborns (14). Torsion of the testis can be seen in all age groups, but with a peak in adolescence (16). This was corroborated by our results where about half of the patients were between l l and 20 years of age. It must be emphasized, however, that even though this age group predominates, the incidence of finding an acute torsion is about the same when exploring the scrotum in patients between 21 and 30 years of age. Torsion of testicular appendages seems to be a rare condition above the age of 20. We have no explanation for this, but the clinical significance of this finding is unimportant, as it is impossible to distinguish clinically between torsion of a testes or an appendage without exploration (15). The anatomical condition which predisposes to torsion of the testis is an abnormality of the suspension (9, 14, 16). These abnormalities are presurnably more common in undescended testes (3) and are often bilateral (6, 9, 15). In this material 14% of the patients with acute torsion revealed maldescenScund J Urol Nephrol24

sus, either on the involved or the contrlateral side. The incidence of undescended testis has been described to be approximately 1 % (13) and torsion of the testis is estimated to occur in one of 160 men before the age of 25. This means that about 5-10% of patients with an undescended testis will experience a case of torsion. The salvage rate of testis was in this study quite high in comparison to previous reports (6, 12). A

Table I. Different diagnosis in 1 1 1 patients operuted on suspicion of testicular torsion No. of patients

Torsion of the testis Acute Acute undescended Recurrent torsions

16

60 4 12

Torsion of testicular appendages

10

Other Epididymitis/orc hitis Idiopathic scrota1 oedema Haernatorna Undescended Miscellaneous

25 10 2 3 4 6

Total

111

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Torsiori o f t h e testis

correlation between duration of the torsion and the degree of late atrophy was found in testes primarily saved, and the fertility was lowered in patients with a previous torsion even if the testes have been saved (7, 15). The differential diagnosis between torsion and other causes for the acute scrotum can be achieved by means of doppler ultrasound or radionuclide imaging (3, 12). As the time from onset of diagnosis to treatment is essential for preservation of testicular function the use of such diagnostic modalities can only be recommended if they can be performed quickly-especially if other diagnoses than torsion are suspected, e.g. in patients above 30 years. In patients suspected for torsion, no diagnostic procedure must delay the exploration of the scrotum. The endocrine function of the testes seem to be mainly unaltered in patients after orchiopexy for torsion (1, 12). This might be due to the fact that the endocrine tissue is rather resistant to ischaemia ( 1 1). This leads to the recommendation of always to leave a non gangrenous testis in situ. However, it is possible that this approach could lead to autoimmunization which might be responsible for the lower quality of semen in patients with previous orchiopexy for torsion (4). Krarup (7) also found impaired exocrine function in patients with unilateral orchiectomy, whereas Bartsch et al. (1) found normal spermiogenesis in these patients. Patients with pathologic semen analysis has a higher level of FSH (1, 12) which is thought to reflect an intact endocrine feed-back mechanism mediated by diminished inhibition of F S H secretion. Further investigations on autoimmunization are needed but might lead to the recommendation to remove a viable testis if the duration of symptoms lasts more than a specified number of hours. Perhaps postoperative testis biopsies can help in this respect. In conclusion, the indications for explorative surgery on the acute scrotum should be wide and not

93

influenced by previous operations. When operating for maldescensus testis o r torsion of the testis it is suggested that the contralateral testes should be fixed, even though the necessity of this surgical approach yet has to be proven.

REFERENCES I . Bartsch G, Frank ST, Marberger H. Mikuz G. Testicular torsion: late results with special regard to fertility and endocrine function. J Urol 1980: 124: 375-378. 2. Delasiauve LJ-F. Descente tardive du testicule gauche, prise pour une hernie etranglee. Rev Med Fr Etrang 1840: 1: 363-375. 3. Haynes BE, Bessen HA, Haynes VE. The diagnosis of testicular torsion. JAMA 1983; 249: 2522-2527. 4. Harrison RG, Lewis-Jones DI, Morendo de Marvdl MJ et al. Mechanism of damage to the contralateral testis in rats with an ischaemic testis. Lancet 1981; ii: 723-725. 5. Johnson MC, Holmes TW. Torsion and the ectopic testis. Surgery 1964: 55: 854-858. 6. Krarup T. Torsion of the testis. Ugeskr Laeger 1976; 138: 728-734. 7. Krarup T. The testes after torsion. Br J Urol 1978; 50: 4346. 8. Mowad JJ, Konvolinka CW. Torsion of the undescended testis. Urology 1978; 12: 567-568. 9. Ransler CW, Allen TD. Torsion of the spermatic cord. Urol Clin N Am 1982; 9: 245-250. 10. Schultz KE, Walker J . Testicular torsion in the undescended testes. Ann Emerg Med 1984; 13: 567-569. I I . Smith GI. Cellular changes from graded testicular ischaemia. J Urol 1955; 73: 355-362. 12. Thomas WEG, Williamson RCN. Diagnosis and outcome of testicular torsion. Br J Surg 1983; 70: 2 13-2 16. 13. Villumsen AL, Zachau-Christiansen B. Spontaneous alteration in position of the testes. Arch Dis Child 1966; 41: 198-200. 14. Whitaker RH. Torsion of the testis. Br J Hosp Med 1982; 1: 6 M 9 . 15. Williamson RCN. Torsion of the testis and allied conditions. Br J Surg 1976; 63: 465-476. 16. Williamson RCN. The continuing conundrum of testicular torsion. Editorial. Br J Surg 1985: 72: 509-510.

S c u d J Urol Nephrol24

Torsion of the testis. A 5-year material.

During a 5-year period 111 patients were operated for suspected torsion of the testis. In 64 patients with an age range from 2 months to 46 years acut...
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