Spermatic cord torsion Testicular torsion

Testicular torsion is a medical emergency that occurs when the testicle rotates around its own axis, twisting the spermatic cord that is responsible for irrigation and blood supply to the testicle. The reduction in blood flow causes testicular ischemia, causing sudden onset of severe pain at the scrotal level.

The degree of twist can vary between 180 and 720 degrees. The greater the degree of torsion, the smaller the influx of blood that supplies the testis and the more quickly irreversible lesions develop in your tissue.

Normally, the testicle is unable to move freely within the scrotum, as the surrounding tissue is consistent and provides adequate support. Patients suffering from torsion of the spermatic cord often have more compromised connective tissue due to malformation present since birth. In these cases, the testicle is not well fixed and can rotate around the its axis, which usually only occurs after puberty, associated with the increase in size and weight of the testicles.

Testicular torsion is more frequent in the age groups between 12 and 18 years old, however, it can occur at any age, even before birth. The first month of a baby's life is also a period of increased risk, even in cases where the aforementioned deformity does not occur.

Any patient with suspected testicular torsion should be immediately evaluated by a urologist. The longer the duration of testicular suffering from ischemia, the greater the likelihood of serious sequelae. In about 1/3 of the cases, patients are not treated in time and end up losing their testicles.

The most common symptom of torsion of the testis is the appearance of a sudden and very intense pain associated with an increase in the volume of the scrotum. The pain may be localized, just on the side of the suffering testicle, or radiate to the inguinal region and lower abdomen. The pain is usually constant, unless the testicle undergoes spontaneous torsion and distortion. Nausea and vomiting are also frequent. Fever or difficulty urinating may occur, but they are not common.

Upon objective examination, the scrotum is enlarged, hardened and flushed. The affected testicle presents pain on palpation and is slightly elevated, caused by the shortening of the twisted spermatic cord.

A typical presentation, particularly at younger ages, is a patient that  wakes up in the middle of the night with sudden scrotal pain. Other situations that can trigger torsion are physical activity or scrotal trauma.

In most cases, the diagnosis can be made through clinical criteria, based on the history, symptoms and data of the objective examination. The use of scrotal ultrasound with Doppler allows clarification of the condition, enabling the assessment of blood flow to the testis.

Testicular torsion is an emergency with surgical treatment.

In some cases the torsion is not complete and there are situations in which the spermatic cord twists and untwists more than once throughout the day, maintaining testicular viability for a longer time.

During the initial evaluation, the urologist may attempt to untwist the testicle manually. This maneuver does not eliminate the need for surgery, but it increases the probability of saving the testicle during the surgical procedure.

Surgery to correct testicular torsion is usually performed under general anesthesia. In this procedure, a small incision is made in the scrotum, the spermatic cord is distorted and both testicles are fixed inside the bag to prevent recurrences (orchidopexy).

If at the time of surgery the testicle already shows evident signs of necrosis, an orchidectomy should be performed, which consists of surgical removal of the testicle, in order to avoid complications due to the presence of dead tissue (infection).

When surgery is not performed in the first 12 hours, the rate of orchidectomy reaches 75%.