Andrew Siegel, M.D. Blog # 89
All organs and tissues need a blood supply to remain alive and vital. The blood supply to each testicle is located within a rope-like “cord” of tissue that travels from the groin into the scrotum. Both the testicular artery and the testicular vein are within this spermatic cord that can be considered to be the life support of the testicle. The artery delivers oxygen and other vital nutrients to the testicle; the veins convey carbon dioxide and other products of cellular metabolism from the testicle to the heart.
Anything that can jeopardize the blood supply to the testicles can affect their vitality. Torsion is defined as a twist of the testes and spermatic cord around a vertical axis, resulting in a kink and thus compromise to the blood flow—this can lead to possible strangulation of the blood supply and infarction (death by lack of blood flow) of the testicle. The testicle can spin 360°, 720° or any conceivable amount. When this occurs, it typically causes an acute onset of pain and swelling in the testicle, and often the pain radiates to the groin and lower abdomen; it can be easily confused with appendicitis when it involves the right testicle. Although torsion can occur at any age, it is most common among adolescents at the time of or shortly after puberty, typically ages 12-20.
When torsion occurs, the spermatic cord is foreshortened and the testicle tends to rise higher in the scrotum than its normal anatomical location. On examination, the twisted testicle is usually very tender and swollen. Torsion is a surgical emergency, because if the testicle is not untwisted on a timely basis, the testicle can die (suffer an infarction). However, when diagnosed on a timely basis, the testis can be untwisted and surgically fixated to prevent recurrent episodes. When it comes to torsion, time is of the essence. It is for this reason that testicular pain needs to be expediently checked out by a medical professional.
Torsion of the testicle can be misdiagnosed as epididymitis, an infection/inflammation of the epididymis which is the sperm storing structure located immediately above and behind the testicle. If the situation is equivocal, a color Doppler ultrasound or testicular scan can be helpful in making the distinction. If there is any doubt, a trip to the operating room is in order.
At times, the testicle can be untwisted in the office or emergency room and the patient can then be electively brought to the operating room where the testicle is fixated to the scrotal skin to prevent it from re-torting in the future. Typically the other testicle is fixated as well. The fixation is done by placing three or so sutures in each testicle, thereby anchoring the testicle to the scrotal wall with this three-point fixation technique.
At other times, the testicle cannot be untwisted and the patient must be brought to the operating room in an emergency (as opposed to elective) basis for a scrotal exploration and untwisting of the testicle under direct vision to determine its viability. Typically once it is untwisted, the testicle shows signs of life (turning from a dusky color to pink), but if too much time has transpired, the testis can appear to be black and necrotic (dead) and instead of being fixed to the scrotal skin, it must be surgically removed. Correction within 6 hours of the onset of pain usually will salvage a testicle.
Bottom Line: Torsion of the testicle is a surgical emergency. If you or someone you know has acute onset of unremitting testicular pain, make sure you/they get to the emergency room ASAP, because time is of the essence with respect to being able to salvage a twisted testicle.
Andrew Siegel, M.D.
Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com
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