Torsion & Orchidopexy


Epidemiology

· Can occur @ any age

— Utero – 70yrs

· Peak 2nd decade

— 65% 12-18

— ? 2° to differential growth of testis & attachments

· Risk by 25yrs

— 1:160

Pathogenesis

· 2% bilateral

· L>R

· By 6hrs seminiferous tubules irreparably damaged

· By 10hrs interstitium irreprably damaged

— Includes Leydig cells

Extravaginal

· Testis & tunica vaginalis twist

· Neonates & undescended testes

— Maldescended testis 10x RR

· Usually infarcted @ presentation

Intravaginal

· 2° high insertion of tunica vaginalis

bell clapper testis. Normally the testis is fixed at the back to the epididymis and the epididymis is not invested on its posterior surface with tunica vaginalis. Thus the testis cannot twist. If the tuncia vaginalis invests the whole epididymis, testis and part of cord, the testis hands like a clapper in a bell and can twist. Alternatively there may be a long mesorchium attaching to testis to an epididymus attached which is normally invested in tunica vaginalis only posteriorly. Here, the body of the epididymis may twist on the fixed epididymis.

· horizontal lie of testis

— abnormality often bilateral

Clinical

· Pain

— Usually sudden onset in scrotum 70%

Occasionally slow…

— Hx of recurrent pain 40%

— Abdominal pain 20%

— Groin pain 10%

— Thigh pain 2%

· Vomiting 40%

· Scrotal swelling

· Testicular tenderness

— Cf epidiymitis

· Scrotal erythema, low grade temp

— Seen with infarction

Ix

· Doppler USS can not exclude torsion – the sensitivity is about 80% and the specificity 100%. The false negatives are due to cases of de-torsion, or early incompletet torsion when flow persists despite torsion being the diagnosis

DD

· Torsion of testis – 30%

· Torsion of appendage  - 60%

· Epidymitis - <10%

— Usually >20yrs usually due to Chlamydia, in young children due to gram negative bacilli from UTI (posterior urethral valves and VUR). Pain is more insidious in onset. Dysuria, frequency, pyuria, thrombbing, constant pain, tender swollen epididymis.

· Idiopathic scrotal oedema - <10%

— Young (3-10 years). Recurrence is common. Manifestation of atopy.

— Scrotal erythema & oedema ± groin

— Palpably normal testis

· Traumatic haematoma

· Acute hydrocele

· Granulomatous orchitis

Rx

· Scrotal exploration

· Bilateral orchidopexy

· If infarcted then orchidectomy


How do you perform scrotal exploration

Torsion of testicular appendage

Epidemiology

· £20yrs

— Rare in infancy. Common in pre-pubertal boy

    occasional in adults

    Pain more localized to antero-superior aspect of testis, blue dot sign may be apparent.

Pathology

· Appendix testis

— Aka hydatid of Morgagni

— Paramesonephric remnant

— 90% in autopsy series

— 70% bilateral

v 95% appendiceal torsions of appendix testis

· Appendix epidiymis (Organ or Giraldes)

— Mesonephric remnant

— 46% autopises

— Always pedunculated

Rx

· Exploration

· Excision

· Where diagnosis is clear and symptoms mild or improving, analgesia alone can be used.