Definition and Overview

Spermatic cord torsion, or testicular torsion, is an emergency medical condition that occurs when the spermatic cord (a cord-like structure that supplies blood to the testicles) becomes twisted. The degree of twisting can be between 180 and 720 degrees. If the testicle rotates several times, the blood flow from the spermatic cord can be completely blocked and this can cause the tissue in the testicles to die.

The condition must be treated with surgery within six hours after the onset of symptoms. The earlier the surgery is performed, the lower is the risk of suffering from irreversible damage that would require the removal of the affected testicle. However, in some men, testicular pain resolves without treatment when the spermatic cord untwists on its own. Though less pressing, this should still prompt them to seek treatment because the condition places them at a significant risk of complete torsion.

The removal of one testicle has minimal to zero effect on a man’s sexual function because his remaining testicle will be able to produce the amount of testosterone and sperm he needs throughout his lifetime. However, in very rare cases of bilateral torsion, the patient will become infertile and will suffer the consequences of not being able to produce the needed male hormones.

Testicular torsion commonly occurs after birth and during puberty. However, it can affect boys and men of any age.

Causes of Condition

The most common cause of spermatic cord torsion is bell clapper deformity, a condition in which the testes are not firmly attached to the lining of the scrotum so they freely float and swing like a bell. Bell clapper deformity accounts for up to 90% of all testicular torsion cases.

Rarely, the condition develops due to trauma to the scrotum or after vigorous activity. In some patients, the cause of the condition is unknown.

Factors that can increase one’s risk of spermatic cord torsion include:

  • Previous testicular torsion - The spermatic cord can twist and untwist on its own without treatment. Unless the patient undergoes surgery to firmly attach the testicles to the lining of the scrotum, his risk of suffering from complete torsion is significantly high.

  • Cold temperatures - Cold weather has been associated with higher incidence of testicular torsion especially in tropic countries.

  • Rapid and unusual growth of testicles during puberty

  • Sleep

Key Symptoms

The most noticeable symptom of testicular torsion is sudden, severe pain in the scrotum and the affected testicle. In some men, the pain goes away without treatment but returns and repeatedly recurs in a matter of days or weeks. This is known as recurrent intermittent testicular torsion. Other symptoms include nausea and vomiting, belly pain, and swelling that makes one testicle visibly bigger or in a higher position than the other. Other signs of the condition include:

  • Lightheadedness

  • Absent or decreased cremasteric reflex - Cremasteric reflex is a superficial reflex observed in human males. Poking or lightly stroking the superior and inner parts of the thigh triggers it.

  • Low-grade fever (rarely)

  • Blood in semen

In newborns who had spermatic cord torsion in utero, symptoms may include undescended, shrunk (atrophic), or non-palpable (testes cannot be felt) testes. Their scrotum or groin region is also often discoloured.

Who to See and Types of Treatments Available

Patients suffering from sudden, intense pain in the testicles or scrotum must seek emergency care. They are often placed under the care of a urologist, a doctor specialising in the diagnosis and treatment of urinary tract problems and disorders that affect the male genitals.

If the condition is diagnosed and treated within four to six hours after the onset of symptoms, there is a 90% chance that the testicle can be saved with surgery. Beyond this time, the risk of losing one’s testicle greatly increases. After 24 hours, there is a 90% chance that testicular tissue will die, which creates the need to remove the damaged testicle.

Tests and procedures to diagnose the condition include:

  • Physical examination of the testicles, scrotum, groin, and abdomen to look for swelling and other abnormalities. The doctor will also check the patient’s cremasteric reflex.

  • Review of the patient’s medical history during which he will be asked about his symptoms and when they started

  • Urine test, which rules out other disorders or diseases, such as infection

  • Ultrasound, which provides doctors an image of the testicles using high-frequency waves. The test can show abnormalities in the scrotum and if blood flow to the area is blocked.

  • Surgery - An open surgery may be performed right away without any other testing if the symptoms have been going on for longer than four to six hours.

The definitive treatment for the condition is surgery, which focuses on attaching both testicles to the scrotum to prevent them from moving or hanging like a bell, which makes the spermatic cord more prone to twisting. The procedure is performed under general anaesthesia either in a hospital’s operating room or at the doctor’s office. For the procedure, the surgeon will:

  • Make a small incision in the scrotum

  • Manually untwist the spermatic cord

  • Secure the testicles to the inside of the scrotum using stitches

  • Close the incision with absorbable sutures

The patient is then transferred to a recovery room until the effects of the anaesthesia wear off. Often, patients are allowed to go home the same day if no complications arise.

In cases where the testicle is left without blood supply for more than six hours and has already sustained irreversible damage, it is removed through a procedure called orchiectomy.

Patients who have had one testicle removed often lead a normal life because their remaining testicle is able to compensate and produce enough testosterone and sperm. This means they will not lose their ability to father children. Once fully recovered, they are given the option to get a prosthetic or an artificial testicle, which doctors found to be helpful in improving patient’s confidence.

References:

  • Roth, C. C., Mingin, G. C., & Ortenberg, J. (2011). Salvage of bilateral asynchronous perinatal testicular torsion. J Urol, 185(6 Suppl), 2464-2468. doi: 10.1016/j.juro.2011.01.013

  • Rampaul MS, Hosking SW. Testicular torsion: most delay occurs outside hospital. Ann R Coll Surg Engl. 1998; 80: 169-172 Ringdahl E, Teague L. Testicular torsion. Am Family Physician. 2006 Nov 15;74(10):1739-1743.

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