IS Case 170: Testicular torsion
Imaging Sciences URMC 2008
Publication Date: 2009-05-21
Patient is an 14-year-old boy with a 12 hour history of right scrotal pain.
Absent Doppler flow within the right testicle. This was manually detorsed by urology and repeat imaging demonstrated hyperemia of the right testicle and epididymis.
Testicular torsion is a twisting of the spermatic cord which can strangulate blood flow to and from the testicle. Although it may occur at any age, it most commonly affects young males, approximately 1 in 4000 under the age of 25. Intravaginal torsion is the most common subtype, accounting for 90% of cases, and typically occurring between the ages of 12 and 18. This type is due to an abnormal testicular suspension known as the bell-clapper deformity and occurs within the tunica vaginalis, hence the term intra-vaginal torsion.
Testicular torsion is one of many diagnostic considerations which exist for acute scrotal pain. The differential also includes epididymo-orchitis, torsion of the testicular appendages, and trauma. Distinguishing among these urgently is necessary given the serious morbidity of testicular ischemia and for treatment planning. When a testicle torses, it has salvage rates near 100% within the first 6 hours, 70% between 6 and 12 hours, and 20% between 12 and 24 hours. Salvage rates after 24 hours are less than 10%.
In addition to patient history and physical exam, sonography has become a valuable tool in assisting the clinician to diagnose the acute scrotum. Grayscale evaluation of partial torsion usually appears normal. Color flow and spectral Doppler evaluation of torsion may demonstrate: (1) Absent arterial and venous flow, (2) increased resistive index on the affected side (diminished or reversed diastolic flow), or (3) decreased flow velocity, low amplitude on symptomatic side.
In the above case, the patient had absence of flow in the affected testicle which became hyperemic after urgent manual detorsion. The patient underwent subsequent bilateral orchiopexy.
- Lin EP, Bhatt S, Rubens DJ, Dogra VS. Testicular torsion: twists and turns. Semin Ultrasound CT MR. 2007 Aug;28(4):317-28. [PMID: 17874655]