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Testis & paratestis

Nonneoplastic lesions

Torsion

Author: Ritu Bhalla, M.D.

Resident / Fellow Advisory Board: Alcino Pires Gama, M.D.

Deputy Editor-in-Chief: Maria Tretiakova, M.D., Ph.D.

Last author update: 31 August 2023

Last staff update: 31 August 2023

Copyright: 2019-2023, PathologyOutlines.com, Inc.

PubMed Search: Testicular torsion

Page views in 2023 to date: 9,248

Table of Contents

Cite this page: Bhalla R. Torsion. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/testistorsion.html. Accessed September 22nd, 2023.

Definition / general

Twisting of the spermatic cord and its contents
Surgical emergency
Reference: Am Fam Physician 2013;88:835

Essential features

Vascular congestion, edema and interstitial bleeding
Hemorrhagic infarction of the testis

ICD coding

ICD-10: N44.00 - torsion of testis, unspecified

Epidemiology

Annual incidence: 3.8 per 100,000 in boys younger than 18 years
2 peaks of incidence: perinatal and puberty
Up to 14% of cases occur in adults
12 - 21% of neonatal cases are bilateral
References: Am Fam Physician 2013;88:835, Am J Emerg Med 2023;66:98

Sites

Testis

Pathophysiology

Twisting of the testicle along the spermatic cord results in reduced venous outflow and vascular congestion
Prolonged twisting impairs arterial flow and ischemia
Prolonged ischemia can result in necrosis
Reference: Am J Emerg Med 2023;66:98

Etiology

Abnormal or absent fixation of testicle and tunica vaginalis
Tunica vaginalis contains the spermatic cord and normally adheres to the posterolateral part of the testicle
Absent or abnormal fixation can result in twisting of the testicle, compromising the blood flow
2 classic anatomic forms
- Intravaginal (more common)
  - Puberty and adulthood
  - Abnormalities in tunica vaginalis attachment
  - Bell clapper deformity: abnormally high reflection of tunica vaginalis, allowing the spermatic cord to twist inside the tunica
- Extravaginal
  - Infancy and childhood
  - Tunica vaginalis is not adhered to the gubernaculum
  - Both the tunica vaginalis and spermatic cord are prone to torsion
References: Am J Emerg Med 2023;66:98, J Ultrasound Med 2022;41:271

Diagrams / tables

Images hosted on other servers:

Bell clapper deformity
leading to intravaginal
testicular torsion

Clinical features

Intravaginal
- Sudden or insidious onset of pain
- Nausea and vomiting
- Followed by swelling of the ipsilateral scrotum
- Most commonly, these symptoms occur several hours after minor trauma or physical activity
- In some instances, history of previous pain
Extravaginal
- May be entirely asymptomatic
- Sole clinical manifestation may be unilateral mass in the inguinal region or in the superior aspect of the scrotum
Reference: Clin Radiol 1999;54:343

Diagnosis

Imperative to rule out testicular torsion in a patient presenting with acute scrotum
High index of suspicion on the part of the physician is needed
Scrotal Doppler ultrasonography is the imaging study of choice (Am Fam Physician 2013;88:835)

Radiology description

Scrotal Doppler ultrasonography
- Flow in the symptomatic testis may be absent, reduced or have abnormally high resistance
- In bell clapper deformity, testis can rotate
  - Doppler ultrasound flow abnormalities can differ depending on the degree of rotation, which ranges from 180° to 270°
- Venous outflow occlusion precedes arterial inflow occlusion
  - Early or partial torsion can result in areas with high resistance flow rather than absent flow owing to compromised venous outflow
- If spontaneous detorsion occurs, Doppler ultrasound flow within the involved testis may increase
Reference: Radiographics 2020;40:529

Radiology images

Contributed by Raman Danrad, M.D.

Ultrasound of bilateral testis

Ultrasound of right normal testis

Ultrasound of left torsed testis

Case reports

13 year old boy with torsion of biolobed testis (Can Urol Assoc J 2010;4:E67)
15 year old boy with testicular cavernous hemangioma associated with testicular torsion (Int J Surg Case Rep 2018;49:247)
16 year old boy with torsion of right undescended testis (Urol Case Rep 2023;50:102480)
57 year old man presented with 9 day history of testicular pain following lawnmowing (J Am Coll Emerg Physicians Open 2021;2:e12545)

Treatment

Prompt restoration of blood flow is critical in cases of testicular torsion
Typically, there is a 4 - 8 hour window before significant ischemic damage occurs
Viability of testicle is difficult to predict, hence emergent surgical management is indicated
Reported testicular salvage rates are 90 - 100% if surgical exploration is performed within 6 hours of symptom onset
Orchiectomy is performed if the affected testicle appears grossly necrotic or nonviable
If the affected testicle is deemed viable, orchiopexy with a permanent suture should be performed to permanently fix the testicle within the scrotum
Contralateral orchiopexy should be performed regardless of the viability of the affected testicle
Reference: Am Fam Physician 2013;88:835

Clinical images

Images hosted on other servers:

Twisting of spermatic cord

Gross description

Depends on the degree of torsion and the time lapse since onset of symptoms
Dark red testis with smooth external surface and solid consistency

Gross images

Images hosted on other servers:

Smooth external surface of torsed testis

Dark red hemorrhagic cut surface

Microscopic (histologic) description

Edema, congestion and interstitial hemorrhage with venous outflow obstruction
Early conservation of germ cells, which later disappear
Initial phase (< 6 hours): dilatation of seminiferous tubules with sloughing of germ cells and vacuolization of Sertoli cells
Followed by pronounced hemorrhage and sloughing of all germ cells
Necrosis of the seminiferous epithelium
Hemorrhagic infarction of testicle
References: Maclennan: Urologic Surgical Pathology, 4th Edition, 2019, Amin: Urological Pathology, 1st Edition, 2014

Microscopic (histologic) images

Contributed by Ritu Bhalla, M.D.

Congestion

Hilar hemorrhage

Sloughing of cells

Interstitial hemorrhage

Residual germ cells

Infarcted tubules

Necrotic parenchyma

Sample pathology report

Testicle, left, orchiectomy:
- Testicular parenchyma with hemorrhagic infarction, consistent with testicular torsion

Differential diagnosis

Systemic vasculitides:
- Can present in 1 of 2 patterns
  - Polyarteritis nodosa pattern
    - Fibrinoid necrosis of medium sized arteries
    - Dense transmural neutrophilic infiltrates
    - Testicular infarct and hemorrhage
  - Granulomatosis with polyangiitis pattern
    - Destructive granulomatous vascular inflammation
Germ cell neoplasia in situ (GCNIS):
- Presence of undifferentiated germ cells within seminiferous tubules; the cells possess
  - Large, hyperchromatic nuclei, with 1 - 2 prominent nucleoli
  - Clear cytoplasm
- Spermatogenesis is usually absent
- Thickened peritubular basement membrane
- OCT 3/4 positive
Regressed germ cell tumor:
- Vascularized fibrotic scar with inflammation
- Surrounding hyalinized or atrophic seminiferous tubules
- Psammomatous calcifications
- Residual germ cell neoplasm or GCNIS may be present
Choriocarcinoma:
- Hemorrhage and necrosis surrounded by cytotrophoblasts and syncytiotrophoblasts
Lymphoma:
- Clonal population of lymphoid cells
Reference: Am J Surg Pathol 2014;38:34

Board review style question #1

A 14 year old boy presents to emergency room with severe left sided testicular pain associated with nausea and vomiting. A Doppler ultrasound shows loss in blood flow in the affected testis. Subsequent orchiectomy reveals red-tan, smooth surfaced testis, with microscopic appearance as seen in the image above. Which of the following can be seen in this condition?

Clonal population of lymphoid cells
Elevated alpha fetoprotein (AFP) levels
Hemorrhage surrounded by trophoblastic cells
Initial preservation of germ cells
Undifferentiated malignant cells within seminiferous tubules

Board review style answer #1

D. Initial preservation of germ cells. The patient's presentation, including imaging and pathology, is diagnostic of testicular torsion. Testicular infarct following torsion is initially associated with conservation of germ cells; however, as congestion and hemorrhage increase, these cells slough into the lumens of seminiferous tubules and ultimately the entire tubule undergoes necrosis. Answer C is incorrect because hemorrhage surrounded by trophoblastic cells is typically observed in choriocarcinoma. Answer E is incorrect because germ cell neoplasia in situ (GCNIS) is associated with undifferentiated malignant cells within seminiferous tubules. Answer A is incorrect because clonal population of lymphocytes is seen in lymphoma. Answer B is incorrect because although AFP can be elevated in several conditions, including yolk sac tumor and teratoma, it is usually not elevated in torsion.

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Reference: Torsion

Board review style question #2

Which of the following is the most common cause of testicular torsion?

Bell clapper deformity
Choriocarcinoma
Cryptorchidism
Mumps orchitis
Varicocele

Board review style answer #2

A. Bell clapper deformity is the most frequent cause of testicular torsion. Tunica vaginalis is normally attached to the testis posterolaterally. In this anomaly, the attachment is abnormally high, which allows the spermatic cord to twist itself within the tunica vaginalis, resulting in testicular torsion. Answer C is incorrect because cryptorchidism may also be associated with torsion but not as frequently as bell clapper deformity. Answers B, D and E are incorrect because varicocele, mumps orchitis and choriocarcinoma are typically not associated with testicular torsion.

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