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Testicular Torsion

Leyla Azmoun, MD
Piran Aliabadi, MD
B Leonard Holman, MD

December 11, 1995

Presentation

A 46-year-old man presented to the emergency room with worsening right testicular pain over the previous four days. He denied any scrotal trauma. On physical exam, the right testicle was enlarged and tender and there was erythema and swelling of the scrotum.

Imaging Findings

Ultrasonography
Doppler ultrasound

Testicular ultrasound shows an enlarged (5.5 x 4.0 x 3.2 cm) right testicle which is diffusely hypoechoic when compared to the left testicle (comparison image). The right epididymis is enlarged and echogenic (arrow). The right scrotal wall appears thickened (arrows). Doppler examination demonstrates diminished flow in the right testicle (arrow) and increased flow in the scrotal wall (arrow). The left testicle and epididymis (arrow) are normal. These findings are consistent with a right testicular torsion.

Diagnosis

Testicular torsion

Discussion

Torsion is a twisting of the spermatic cord upon itself that results in obstruction of the blood vessels supplying the testis and epididymis. It is usually the result of anomalous suspension of the testes within the scrotum. Torsion is more common in children, but accounts for 20% of acute scrotal pathology in post-pubertal males. Testicular torsion and acute epididymitis or epididymo-orchitis are the most common causes of an acute scrotal pain. Differentiating between these entities is often difficult on physical examination and testicular sonography with pulsed and color Doppler examination is helpful in this regard. On sonography, the torsed testicle is usually enlarged and hypoechoic compared with the contralateral normal testicle, and may contain echogenic areas representing hemorrhage. Common extra-testicular findings include an enlarged epididymis, skin thickening and reactive hydrocele formation. The gray-scale findings are not specific and may also be seen in epididymo-orchitis. However, decreased or absent blood flow within the testicle on Doppler examination indicates acute torsion.

Radionuclide imaging with Tc-99m pertechnetate can complement ultrasound in differentiating torsion from epididymo-orchitis. There is diminished or absent blood flow to the torsed testicle compared to increased blood flow in epididymitis or orchitis. Delayed images in torsion show increased peripheral activity around a cold testicle.

Prompt diagnosis and treatment of testicular torsion is essential for testicular salvage. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 70% of cases. Delayed treatment results in a much lower salvage rate.

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