Testis & paratestis
Nonneoplastic lesions
Torsion
Authors: Sarah Findeis, M.D., He Huang, M.D., Ph.D.
Editor-in-Chief: Debra L. Zynger, M.D.
Last author update: 25 June 2019
Last staff update: 26 January 2021
Copyright: 2019-2023, PathologyOutlines.com, Inc.
PubMed Search: Testis and epididymis torsion AND (free full text[sb])
Table of Contents
Definition / general | Essential features | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Radiology description | Radiology images | Case reports | Treatment | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Findeis S, Huang H. Torsion. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/testistorsion.html. Accessed March 24th, 2023.
Definition / general
- Surgical emergency due to twisting of the testicle around the spermatic cord or vascular pedicle attachments (Semin Ultrasound CT MR 2017;38:327)
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
- Annual incidence: 3.8 per 100,000 for males younger than 18 years (Am Fam Physician 2013;88:835)
- Mostly under 18 years old, with bimodal distribution (neonatal and puberty) (Am Fam Physician 2013;88:835)
- Unilateral scrotal pain, nausea and vomiting (Am Fam Physician 2013;88:835)
- Absent cremasteric reflex suggests torsion (Am Fam Physician 2013;88:835)
- Ranges from partial to complete torsion (Radiol Clin North Am 2019;57:635)
Sites
- Repetitive
Pathophysiology
- Venous compromise, which turns to arterial occlusion and then ischemia (Semin Ultrasound CT MR 2017;38:327)
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
- Predisposing factor is “bell-clapper” deformity: tunica vaginalis envelops testis, epididymis and distal spermatic cord (Radiographics 2013;33:721)
- Deformity typically bilateral (Radiol Clin North Am 2019;57:635)
- Causes increased mobility (Am Fam Physician 2013;88:835)
- Radiologically, can be confused with segmental testicular infarction but this is clarified at the time of surgery
- Small study showed minute (6.4%) association between testicular torsion and testicular cancer (Clin Genitourin Cancer 2016;14:e55)
Diagnosis
- Clinical diagnosis (Am Fam Physician 2013;88:835)
Radiology description
- Can be identified on scrotal ultrasound and can give an approximate time as to how long it has been torsed:
Radiology images
Images hosted on other servers:
Testicle infarction (Case 3)
Comparison of torsed and non-torsed testicle (Case 22)
Case reports
- 15 year old man with testicular cavernous hemangioma associated with testicular torsion (Int J Surg Case Rep 2018;49:247)
- 27 year old man with simultaneous testicular tumor and contralateral torsion (Urology 2000;55:590)
- 40 year old man with large bilateral spermatoceles and testicular torsion (Qatar Med J 2016;2016:10)
Treatment
- If viable, detorsion and orchidopexy, otherwise orchiectomy (Radiol Clin North Am 2019;57:635)
- 42% undergo orchiectomy during surgical evaluation (Am Fam Physician 2013;88:835)
- Contralateral orchiopexy done because etiology is unknown (Am Fam Physician 2013;88:835)
- If clinical symptoms highly suggestive, patient should go emergently to surgical exploration (Am Fam Physician 2013;88:835)
Clinical images
Images hosted on other servers:
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 Sarah Findeis, M.D.
Torsed testicle
Images hosted on other servers:
Bilateral torsion
Microscopic (histologic) description
- Hematoma / hemorrhage of parenchyma (Am J Surg Pathol 2014;38:34)
- More likely to be dissecting interstitial hemorrhage than a hematoma (Am J Surg Pathol 2014;38:34)
- Damaged blood vessels with coagulative necrosis (Am J Surg Pathol 2014;38:34)
- Ghost outlines of tubules with necrotic germ cells (Am J Surg Pathol 2014;38:34)
- Adjacent testis has tubular atrophy and sclerosis, granulation tissue or fibrosis and interstitial inflammation, usually lymphohistiocytic (mainly T cells) (Am J Surg Pathol 2014;38:34)
- Veins can be dilated and filled with blood (Am J Surg Pathol 2014;38:34)
- Involves both arteries and veins, including intratesticular and paratesticular vessels (Am J Surg Pathol 2014;38:34)
- Often intimal thickening in arteries (Am J Surg Pathol 2014;38:34)
- Often mural sclerosis in veins (Am J Surg Pathol 2014;38:34)
Microscopic (histologic) images
Contributed by Sarah Findeis, M.D.
Necrosis
Dilated vessels
Widespread necrosis
Intratesticular hemorrhage
Sample pathology report
- Testicle, left, orchiectomy:
- Testicular parenchyma with hemorrhage and necrosis, consistent with testicular torsion
Differential diagnosis
- Germ cell neoplasia in situ:
- Large germ cells that have polygonal nuclei with flattened edges, prominent nucleoli and clumped chromatin
- OCT3/4 positive (Am J Surg Pathol 2014;38:34)
- Systemic vasculitides (polyarteritis nodosa, Henoch-Schönlein purpura, Goodpasture syndrome, Wegener granulomatosis):
- Polyarteritis nodosa is highest on the differential for vasculitides
- Mixed type acute inflammatory cells (seen in polyarteritis nodosa)
- Correlation with lab values may be helpful (Am J Surg Pathol 2014;38:34)
- Choriocarcinoma:
- Rims of neoplastic trophoblast cells, lacks ghost cells (Am J Surg Pathol 2014;38:34)
- Lymphoma:
- Clonality and atypia present in the lymphocytic infiltrate
- Sarcoma:
- More cellular (Am J Surg Pathol 1992;16:448)
- Idiopathic spontaneous intratesticular hemorrhage:
- Intact seminiferous tubules (Urol Case Rep 2017;14:33)
Board review style 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?
- Acute inflammation
- Cellular fibroblastic proliferation
- Coagulative necrosis
- Preserved seminiferous tubules
- Venous intimal thickening
Board review style 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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Board review style question #2
- What feature is most useful when distinguishing testicular torsion from a polyarteritis nodosa?
- Clinical history
- Fibrinoid vascular necrosis
- Lab values
- Presence of ghost cells
- Acute inflammatory cells
Board review style 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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