Testicular Torsion

Introduction and Epidemiology

Testicular torsion is the twisting of the spermatic cord and its contents, requiring fast diagnosis and management. The annual incidence is about 3.8 per 100,000 males under 18 years old. Roughly 10% to 15% of acute scrotal issues in children are due to torsion, resulting in a 42% rate of orchiectomy (removal of the testicle) in boys treated surgically for testicular torsion.

The incidence of torsion according to the age shows two peaks, the first of them in neonates and the other one around puberty. In neonates, extravaginal torsion is common, where the entire cord, including the processus vaginalis twists, and it can present as a painless scrotal swelling. Testicular survival in neonatal torsion is generally low, with a salvage rate of around 9%. In older children and adults, testicular torsion is usually intravaginal, in which the twisting of the cord occurs within the tunica vaginalis [1].

Diagnosis

Testicular torsion must be suspected in every patient presenting with an acute onset scrotal pain without previous trauma. Medical history may be poor since children may not describe accurately symptoms, but it usually presents as a unilateral testicular pain associated with nausea and vomiting, sometimes [1]. Differential diagnosis includes epididymo-orchitis, infection, inguinal hernia or hydrocele and torsion of the spermatic cord [1][2]. Patients with highly suggestive history and physical examination do not need imaging and can undergo immediate surgery, since any delay can decrease the survival chances of the affected testis, mainly after 6 hours of the onset of pain [2]. When it comes to questionable diagnosis doppler ultrasonography of the scrotum can be done, which is a highly sensitive (88.9%) and specific (98.8%) preoperative diagnostic tool with a 1% false-negative rate [1].

Anesthetic Management

• Standard monitoring;
• Since patients with suspicion of testicular torsion are considered to have a full stomach Rapid Sequence Induction is indicated [2];
• Secure the airway with tracheal intubation to avoid bronchoaspiration [2]
• Usually there is important relieve of pain after the torsion is solved, so there is no any specific consideration about analgesic management[2].

Although the previous recommendations, there are some case reports describing the orchiectomy due to testicular torsion under regional anesthesia[3][4].

References

[1] Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15;88(12):835-40. PMID: 24364548.

[2] Cote CJ. A Practice of Anesthesia for Infants and Children. 6th edition. Elsevier, 2017.

[3] Fernandez N, Santander J, Ceballos C. Regional Anesthesia. An Alternative to General Anesthesia in the Management of Neonatal Testicular Torsion. Urology. 2020 Dec;146:219-221. doi: 10.1016/j.urology.2020.06.037. Epub 2020 Jul 6. PMID: 32645373.

[4] Heap G. Correcting torsion of the testis under local anaesthetic. ANZ J Surg. 2003 Jul;73(7):551. doi: 10.1046/j.1445-1433.2003.02688.x. PMID: 12864838.

Urgent surgical exploration for neonatal torsion under spinal anesthesia