Testis and epididymis
Nonneoplastic lesions
Torsion

Senior Author: He Huang, M.D., Ph.D.
Editor-in-Chief: Debra Zynger, M.D.
Sarah Findeis, M.D.
He Huang, M.D., Ph.D.

Topic Completed: 25 June 2019

Revised: 25 June 2019

Copyright: 2019, PathologyOutlines.com, Inc.

PubMed Search: Testis and epididymis torsion AND (free full text[sb])

Sarah Findeis, M.D.
He Huang, M.D., Ph.D.
Page views in 2018: 4,584
Page views in 2019 to date: 2,898
Cite this page: Findeis S, Huang H. Torsion. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/testistorsion.html. Accessed July 17th, 2019.
Definition / general
Essential features
  • Hemorrhage with varying amounts of necrosis depending on the amount of time that has passed
  • Prominent dilated veins typical but not necessary
  • Clinical correlation with operative note can be helpful as there often is visible twisting of spermatic cord
ICD coding
  • ICD10: N44.00 - torsion of testis, unspecified
Epidemiology
Sites
  • Repetitive
Pathophysiology
Etiology
  • Preliminary studies in mice and a small pediatric study suggest it may be related to involvement by the INSL3 gene variations as a predisposing factor (Pediatr Surg Int 2018;34:807)
Clinical features
Diagnosis
Radiology description
  • Can be identified on scrotal ultrasound and can give an approximate time as to how long it has been torsed:
  • Early stages: normal grayscale
  • Between early and 24 hours: enlarged and hypoechoic
  • After 24 hours: hemorrhage and necrosis causing heterogeneous echogenicity (Radiol Clin North Am 2019;57:635)
  • Salvageability can be determined by if there is normal or abnormal echogenicity (J Urol 2008;180:1733)
  • Radiology images

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    Testicle infarction (Case 3)

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    Comparison of torsed and non-torsed testicle (Case 22)

    Case reports
    Treatment
    Clinical images

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    Torsion of spermatic cord

    Gross description
    • Enlarged, congested purple testicle with hemorrhagic with or without necrosis (Am J Surg Pathol 2014;38:34)
    • Twisting of spermatic cord may be visible
    Gross images

    Contributed by Jennifer Findeis-Hosey, M.D.
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    Torsed testicle


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    Bilateral torsion

    Microscopic (histologic) description
    Microscopic (histologic) images

    Contributed by Jennifer Findeis-Hosey, M.D.
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    Necrosis

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    Dilated vessels

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    Widespread necrosis

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    Intratesticular hemorrhage

    Sample pathology report
    • Testicle, left, orchiectomy:
      • Testicular parenchyma with hemorrhage and necrosis, consistent with testicular torsion
    Differential diagnosis
    Board review question #1
      A 3 year old boy presents to the emergency room with unilateral scrotal pain and vomiting for the last 37 hours. The patient is rushed to surgery and unilateral orchiectomy is performed. What is one of the histologic findings you would likely see in testicular torsion?

    1. Acute inflammation
    2. Cellular fibroblastic proliferation
    3. Coagulative necrosis
    4. Preserved seminiferous tubules
    5. Venous intimal thickening
    Board review answer #1
    C. Damaged vessels with associated coagulative necrosis is seen in testicular torsion. Fibroblastic proliferation may be seen but it should be paucicellular, not cellular. The inflammatory infiltrate will be lymphohistiocytic. The seminiferous tubules will be degenerated. The arteries may have intimal thickening, but not the veins.

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    Reference: Torsion
    Board review question #2
      What feature is most useful when distinguishing testicular torsion from a polyarteritis nodosa?

    1. Clinical history
    2. Fibrinoid vascular necrosis
    3. Lab values
    4. Presence of ghost cells
    5. Acute inflammatory cells
    Board review answer #2
    E. The inflammatory cells with testicular torsion are frequently lymphohistiocytic instead of the mixed inflammatory cells of a polyarteritis nodosa. Clinical history is useful but often can overlap for both entities at presentation. Fibrinoid vascular necrosis can be seen in both entities. Presence of ghost cells is a useful feature when distinguishing choriocarcinoma from testicular torsion. Lab values can be helpful but may not rise until after orchiectomy.

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    Reference: Torsion
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