This article will touch upon testis torsion, meaning when the eggs turn around their blood vessel stem. We will explain the importance, functions, anatomy and disorders of the testes in order to better clarify the subject.
What is Testis?
Testes are part of the male reproduction system. If forms in the mother womb, behind the waist at the kidney region. It descends towards the groins. It passes through the inguinal channel. It is settled in the scrotum in newly born babies. The scrotum (testis bag) is special formation. It has the feature of keeping its internal temperature at a certain degree. It shrinks under cold and relaxes under heat and therefore keeps a fixed temperature for sperm generation. The temperature of human body is 36.8-37 degrees. The temperature in the testes is 34-36 degrees. There are microscopic channels inside the testes that total 400 meters in length. Spermatozoa are produced within these channels. Also, the special cells around these channels secrete testosterone. Sperms mature and pass through these channels. They continue to mature in the channel called epididymis. And they go to the seminal vesicles through the vasa efferentia, where they are stored. A mature male produces one million sperms per day. Sperms are ejaculated from the penis within a milky (ejaculate) environment. Males can achieve impregnation ability between 11-17 years of age. Testes begin to grow between 10-13 years of age.
What are the Causes of Pain and Swelling in the Testis?
Testis torsion (turning) isn’t always the cause behind pain and swelling in the testes. It is important to accurately evaluate and diagnose the cause of swellings.
Water may accumulate around the testis. This is called hydrocele, which means water sag.
It may be testis inflammation associated with sexually transmitted diseases (epididimo orchitis).
The groin channel (inguinal canal) provides a connection between the abdominal cavity and the scrotum. Any rupture in this cannel lead to organs within the abdomen such as intestines to slip inside the scrotum. This is called inguinal hernia.
Testes may be injured due to kicking, impact or crushing (testicular trauma).
The blood vessels for testes arrive and leave from the rear of the abdomen. Venous blood vessels of the testis may expand (varicosele).
Testis cancer occurs when the testis cells grow abnormally. The testis grows. But there is no pain. There may be blunt pain at the waist region.
Testis torsion is characterized with intense pain. This pain occurs when the testis turns around its blood vessel stem.
In adolescents, the secretion by testis when thinking about women causes to testis to stretch and therefore yields pain. It disappears with masturbation.
There are 1-2 mm formations on the upper section of the testis and on the head of the epididymis, which we call epididymal appendicitis. These may also suffer torsion (turning). It may manifest similar pains. But these are unimportant. They don’t require surgery. The pain disappears by itself (appendicitis testis torsion). Experienced physicians easily diagnose it. It doesn’t require treatment. It is seen in children between ages of 7-12. It isn’t dangerous.
What is Testis Torsion?
In a normal adult, the testis has been fixated from both the upper and the lower pole. Normally, it cannot turn around the blood vessel stem. Tunica vaginalis is a balloon shaped membrane that wraps the testis at the lower and upper poles. And this balloon also prevents the testis to turn around its stem (spermatic cord). Testis Torsion occurs when the stem called aspermatic cord turns (twists) 90-180-360-720 degrees around its axis. The child generally wakes up during the night with sudden and intense pain. The spermatic cord (the blood vessel stem above) consists of the arteries, venous blood vessels and nerves of the testis, and the channel that conveys sperm, which is called vas deferens. Testis torsion (turning) disrupts the blood flow in the testis and results in gangrene (necrosis). There is intense pain. It requires urgent surgery. Only early diagnosis and treatment can protect the secretion of testosterone and sperm production by the testis. In case of a full turn, testis torsion can be corrected by a surgery performed within 6 hours. There can be familial predisposition. If children have relatives that have suffered testis torsion, these should be followed-up closely.
In which period is testis torsion seen?
It frequently occurs in newly born children and adolescents. But it is also seen in men between 40-50 years of age, although rare.
Can testis torsion accompany testis cancer?
Yes. More than half of testis torsion may accompany testis cancer. The testis blood stem, which grew and got heavier due to cancer, is more inclined to turn around itself.
Why does Testis Torsion Require Emergency Treatment?
Turning 1 time around is axis is 360 degrees and 2 times is 720 degrees. This turning is called complete torsion in medical language. This can also occur in form of quarter turning (90 degrees) or half turning (180 degrees) (incomplete torsion). The arteries and veins of the testis are blocked due to the degree of torsion. Arteries cannot carry blood. And the veins that carry venous blood cannot discharge it. Infraction, meaning gangrene occurs. The organ attains a charcoal color and decays. It therefore requires immediate intervention.
Symptoms of Testis Torsion
A good query is important. Intravaginal torsion (inside the testis membrane) emerges with a suddenly occurring intense pain at one side of the scrotum. There is swelling in the groin and the sac. It may occur pursuant to sports activity or trauma to the testis. It may also occur without no reason. One-third of patients may suffer nausea and vomiting. Presence of nausea and vomiting is an important finding for torsion.
Diagnosis of Testis Torsion
A specific scoring system. Swelling in testis (2) hardness in testis (2), loss of cremaster reflex (1), nausea, vomiting (1), examining the testis in horizontal position instead of vertical (1). An experienced physician can classify the patient to be under low, medium and high risk according to this scoring. Score of 5 and 6 mean high risk. The patient should be operated without waiting for other examinations. Scoring below 3 allows examination and imaging for conclusive diagnosis.
Ultrasonography in Testis Torsion
An experienced physician can diagnose 95% of cases only with physical examination. Time spent with unnecessary examinations can kill the testis. There is nevertheless benefit in evaluating the testis by ultrasonography if there is no loss of time. When there is low suspicion for testis torsion, Doppler and Power Color Ultrasonography can be performed, which show the operation of testis blood vessels with ultrasound. It shows arterial blood flow. Imaging can show the reduction of blood flow in testis or the complete loss thereof. It also shows whether the testicular torsion is partial or full.
Nuclear imaging in testis torsion (Radionuclide scan)
As it shows blood flow, it may be beneficial for showing disorders outside the testis as it shows blood flow (when there is low suspicion for torsion and no emergency exists). It allows 90-100% diagnosis for torsion.
Types of Testis Torsion
There are 2 types of testis torsion: intravaginal torsion (inside the testis membrane) and extravaginal torsion (outside the testis membrane).
Baby torsion (Extra vaginal torsion)
Baby torsion (Extra vaginal torsion) is around 5%. 70% thereof occurs in mother womb (prenatal) and 30% occurs after birth (postnatal). Extra vaginal torsion occurs when the stem turns outside tunica vaginalis, which is the sac surrounding the testis. Number of cases where torsion occurs in both testes isn’t rare. Below our article, you can find the surgery video of a case that we operated 2-3 days after birth. Torsion in the newly born is different. It is seen in babies newly born 3-5 days ago. It occurs when the lower pole of the testis is not yet fixated on the scrotum (testis base). Meaning that the membrane called tunica vaginalis, which surrounds the testis, hasn’t yet adhered to the testis base by a bond called the gubernaculum.
Intravaginal Torsion occurs below 30 years of age and especially between 12-18 age interval. 1/5 of the patients that apply to emergency clinic due to pain and swelling are diagnosed with intravaginal torsion. It is more common in the left. Intravaginal means the turning of testes inside the tunica vaginalis membrane. This anomaly is present in 12 percent of men. It occurs in both sides in 40 percent. This type mainly occurs in adolescents and advanced ages. The testis grows and becomes heavy in adolescents. Also, there are sudden spams in the cremaster muscle that is located right under the scrotum skin. The stem may turn 90-180-360-720 degrees around itself.
What Happens if Testis Torsion isn’t Treated?
Infarction occurs, the testis decays and gets inflamed. Infertility may occur. Loss of testis may create psychological problems associated with cosmetic appearance. One testis disappears in the scrotum of such patients. Although hormone secretion is below normal in single-sided cases, this doesn’t create problems. Secretion by the intact testis maintains male functions. If the patient’s one testis has been removed due to decay, there is always a possibility of torsion in the other testis. For this reason, intact testis should also be fixated on the bases of the scrotum base by surgery.
The patients should-be followed up by sperm analysis for risk of infertility. Studies show that the testis in the intact side can be effected from the damage in the twisted testis and that quality and number of sperms can be low.
Testis Torsion Surgery
The main principle is immediate surgery for rescuing the testis. We don’t wait for laboratory examinations and imaging methods. We race against time. Unfortunately, time loss occurs in many cases due to waiting for examination and imaging results. And the testes cannot be rescued. Ultrasonography and nuclear examination can be performed if there is less suspicion for testicular torsion.
A 2-4 cm incision made from the groin region or over the sacs. The membrane over the testis is open. The torsion (turning) is correcting by turning the testis towards the opposite side. We apply heat in order to increase blood flow and observe whether there is blood built-up in the testis. In the meanwhile, an incision is made at other side of the groin in order to solidify the other testis. The intact testis is fixated onto the scrotum base in order to prevent possible torsion in the future. The turned testis is fixated onto its position if it blood built-up has occurred and its color became partially lighter. If there is no blood built-up, this means that the testis has decayed. The testis is incised and removed.