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

• The patient is consented for bilateral exploration, bilateral orchidopexy and orchidectomy.
• GA. Supine. IV abx. TEDS. SCD. Time out. Sterile prep and drape or both testis.
• Perform a median raphe incision cutting through skin using cutting diathermy.
• Displace testis medially so that soft tissues on the appropriate side are divided using diathermy including dartos, external spermatic fascia, cremasteric fascia, internal spermatic fascia.
• Cautiously open the parietal layer of tunica vaginalis by picking it up between two artery forceps and widen the incision to deliver the testis.
• Viewed from below an anti-clockwise rotation is required for the right side and a clockwise rotation for the left side – away from midline somewhere between 180-720 degrees
• If the testis is dusky or black, it is placed in a sponge moistened with warm saline and left for 10 minutes.
• If after this the testis remains black, then an orchidectomy is required. Clamp the cord with two large arteries. Double tie the proximal cord with 0 Vicryl transfixing suture and then 0 Vicryl tie. Then cut the cord leaving both ties. The contra-lateral exploration and fixation is then required.
• If the testis is viable then perform bilateral fixation.
• To perform fixation, I use a 2/0 prolene suture. I evaginate the scrotum and place a suture in the parietal layer of tunica vaginalis and then a suture in corresponding place in testis ( taking care not to penetrate deeply).
• Place 3 sutures, one at lower pole, one at right and left sides. Tie all sutures only after placed.
• Through the same incision dissect into the contrelateral sac and perform fixation as above
• If torted appendix testis or epididymis then place a 2/0 Vicryl tie and excise.
• If epididymitis, then washout with saline
• Closure in layers with 2/0 Vicryl to tunica vaginalis, continious 2/0 Vicryl to dartos and interrupted 3/0 Monocryl to skin.
• Scrotal support.
  

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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.