1. Testis / Spermatic cord TORSION
Naser Moradi MD
Assistant professor in Urology

2. Anatomy
Normal Bell – clapper deformity Appendages : testis ( Mulerian ) Epididymis ( Wolfian )

3. Incidence
1/4000 males < 25 yr.s old Perinatal # 10% ( 70% prenatal ) Peripubertal ( 12 – 20 yr.s old ) Ages 4 to 6 yr.s ( hyperactive cremaster )

4. Etiology
Increase of testis volume ( puberty , tumor ) Bell – clapper deformity UDT ( intra abdominal ) Activity of cremaster muscle

5. Differential diagnoses of Acute scrotum
Torsion of appendix testis Torsion of appendix epididymis Epididymitis Epididymo-orchitis Inguinal hernia Trauma Insect bite Testis tumor Skin diseases

6. Acute scrotum in children
Melekos (1988) : 100 children < 15 yr.s 42% Testis torsion 32% appendages torsion ****************************** 16% testis torsion 46% appendix torsion 35% other causes

7. UDT & Testis torsion
Torsion of undescended testis in a baby receiving hormonal therapy (1993). Reigler (1972) : 64% of torsed UDTs in adults had tumors.

8. Testis torsion
1.Extravaginal 2.Intravaginal

9. Symptoms & history
1, Pain : acute scrotal (90%) 2, pain : inguinal & lower abdomen 3, Nausea & vomiting (40%) 4, Acute abdomen 5, previous similar history (36%) 6, Usually occurring at rest (4% previous trauma & 10% after exercise ) 7, Usually no urinary symptom ( < 5% )

10. Signs
1, Oedema & erythema of hemiscrotum 2, high riding testis : tender , firm ,horizontal 3, Epididymis not palpable or dislocated 4, Fixed testis (no free movement) 5, Cremasteric reflex : absent 6, Prehn,s sign : negative 7, No fever / leukocytosis

11. Perinatal testis torsion
1, Extravaginal 2, Nontender firm testis 3, No erythema / oedema of scrotum 4, Discolored scrotum fixed to testis 5, Testis is almost always necrotic 6, Neonatal operation (inguinal) : ?

12. Diagnosis
*** History & age *** Physical exam *** Absent cremasteric reflex Color doppler ultrasonography : sensitivity 90% specificity 99% false positive 1% Lab. Exams : CBC & U/A Isotope scan *** Surgical exploration

13. Animal study
Blood vessels obstruction 6 hours => death of sertoli & spermatogenic cells 10 hours=> death of Leydig cells

14. Human
Severe atrophy of testis has been seen with “4 hours “ of ischemia In general : Testis atrophy is uncommon if torsion is treated up to 8 hours of onset of symptoms

15. Treatment
Manual detorsion Emergency surgical exploration Bilateral orchiopexy