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I.7 Problem: Emergencies in Andrology

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I.7 Problem: Emergencies in Andrology Chapter I.7 I.7 Problem: Emergencies in Andrology I.7.1 Testicular Torsion C.F. Heyns, A.J. Visser Key Messages ulative detorsion of the testis (Nash 1893). Curling ■ Torsion of the testis is a common emergency. (1857) cited a case report by Rosenmerkel from Munich, ■ The diagnosis is clinical and the management who untwisted an undescended testis and fixed it in the is emergency surgical reduction and bilateral scrotum with a stitch through the dartos tunics (Noske fixation. et al. 1998). Defontaine described the first case of opera- ■ A high index of suspicion is imperative in tive reduction of an intrascrotal torsion in 1893 (Sparks equivocal cases, and errors in management 1971). Taylor first described extravaginal torsion in should be on the aggressive rather than the 1897 (Taylor 1897). conservative side. By 1901, Scudder was able to assemble only 32 cases ■ Ipsilateral and contralateral orchiopexy should from the world literature (Williamson 1976). Before be performed with nonabsorbable sutures to 1919, only 124 cases had been reported, but between prevent recurrent torsion. 1923 and 1930 there were 250 reported cases, probably ■ The testicular salvage rates correlate with the due to wider recognition of the condition (O’Conor duration and the degree of torsion. 1933). ■ Subfertility after torsion is well recognized but We reviewed 276 articles, performed meta-analyses probably not of clinical importance. on the published data and reported our findings in two ■ Testicular torsion remains a surgical emer- recent reviews, which can be consulted for the most im- gency until 48 h of persistent symptoms have portant articles (Visser and Heyns 2003, 2004). elapsed. ■ In the presence of woody scrotal induration, I.7.1.1.1 testicular torsion is no longer an emergency Intravaginal Torsion after 24 h of persistent symptoms. ■ Patients with a clinical diagnosis of intermit- Intravaginal torsion (IVT) is by far the most common tent or recurrent subacute torsion, and those type of torsion. The testis usually undergoes torsion on with loss of one testis due to previous torsion, the last few centimetres of the spermatic cord within trauma or tumour, should probably undergo the tunica vaginalis. The predisposing anatomical fac- elective orchiopexy. tors are: ■ Torsion of the testicular appendages can be 1. A spiral arrangement and low insertion of the managed conservatively and has no clinical fibres of the cremaster muscle. importance, except that it must be distin- 2. A tunica vaginalis, which extends proximally guished from torsion of the testis. around the spermatic cord – the bell-clapper deformity. 3. An abnormality of the junction of the epididymis I.7.1.1 with the testis, forming a mesorchium (Jones Definition 1962). Torsion of the testis was first described by Delasiauve in Our current understanding of the mechanism and un- 1840 (Delasiauve 1840). The first case of torsion of a derlying anatomical abnormality can largely be credit- fully descended testis was reported by Langton in 1881 ed to the work of Muschat who coined the term “bell- (Williamson 1976). In 1893, Nash first described manip- clapper” in 1932 when he described the findings in a I.7.1 Testicular Torsion 135 case of intravaginal torsion (Muschat 1932). He postu- The bell-clapper deformity is found in 12% of autop- latedthatduringdescentofthetestis,thepositionofthe sies, and is bilateral in 66% of these cases, suggesting scrotal organs is different in relation to the tunica vagi- that it is a common deformity in the human and more nalis. Instead of descending posterior to the tunica vagi- prevalent than torsion is manifest clinically (Caesar nalis with partial covering of the descending organs, the and Kaplan 1994a). In testicular torsion, the bell-clap- testis and epididymis bulge into the vaginal sac and per deformity is found in 71% to 75% of cases (Cass et continue to descend into the sac until testis, epididymis al. 1980; Ransler and Allen 1982). and a portion of the spermatic cord are completely cov- Mesorchial torsion is found in 9% to 25% of cases, ered by the tunica vaginalis (Muschat 1932). and the abnormality is present on the contralateral side The term “mesorchium” has been used to describe in 55% to 100% (Ransler and Allen 1982; Anderson two things: and Williamson 1988). Some purists prefer the term “torsion of the sper- 1. The mesentery attached to the posterior aspect of matic cord” instead of “torsion of the testis”. However, the epididymis, and running vertically from the from the above it is clear that torsion does not always globus major to the globus minor. This arrange- involve the spermatic cord. ment is found in the normal testis, in which it acts as a stabilizing factor. 2. The thin linear attachment of the epididymis to the I.7.1.1.2 testis (Fig. I.7.1). This type of mesorchium may be Extravaginal Torsion, Torsion of the Spermatic Cord, important if the torsion occurs between the testis Supravaginal Torsion and the epididymis, which is a rare cause of intra- Sir Astley Cooper in 1830 first noted that the entire vaginal torsion (Jones 1962). scrotal contents of the neonate could be freely lifted out Intravaginal torsion is possible at three different levels: of the scrotum without tearing any tissue, and this mechanism is believed to account for the rare extravag- 1. The intravaginal spermatic cord may rotate and inal torsion, which is found in neonates, where the en- cause infarction of the testis and epididymis, which tire testis complex twists en bloc (Williamson 1976). isthemostcommontype(bell-clapperdeformity). Jerkins et al. (1983) postulated that fixation of the testis 2.Therotationalplanemaybethroughthemesorchi- to the scrotal wall occurs between 7 and 10 days after um between the testis and epididymis, causing in- I.7 birth. However, fixation may take place later, since ex- farctionofthetestisonly,whilesparingtheepidid- travaginal torsion has been reported in a 5-week-old ymis (mesorchial torsion). boy who was born at 36 weeks gestation (Kaufman 3. Torsion may rarely occur through the mid epididy- 1984). mis, where part of the epididymis will be spared (epididymal torsion) (Parker and Robison 1971). Fig. I.7.1. The anatomy of (a)normal attachments, (b) bell-clapper deformity, (c) abnormal mesorchium and (d)intravaginal torsion (Modified from Stillwell and Kramer 1986) 136 I.7 Problem: Emergencies in Andrology I.7.1.1.3 I.7.1.2.1 Spontaneous Detorsion Intravaginal Torsion Anatomical Predisposition Spontaneous detorsion may occur at the time of anaes- thesia or before in 10% to 25% of cases, probably due to Up to 12% of the male population has an abnormal tes- cessation of the cremasteric spasm that maintains the ticular attachment (bell-clapper deformity), although torsion (Cass et al. 1980; Ransler and Allen 1982). the occurrence of testicular torsion in the general pop- ulation is much lower (Caesar and Kaplan 1994a). I.7.1.1.4 Intermittent Torsion, Subacute Torsion, Subtorsion Initiating Force Van der Poel described the first case of intermittent tor- Cremasteric spasm associated with sleep, trauma, vig- sion in 1895 (Schulsinger et al. 1991). Various activities orous exercise or cold weather may be the initiating are associated with intermittent torsion, including ex- force (Williamson 1985). ercise, walking, sitting, standing, sleeping, coughing, leg crossing, straining at stool and coitus (Schulsinger Cold Weather et al. 1991). Anderson and Williamson (1988) reported that in Several reports suggest that cold weather may predi- 76% of cases of recurrent subacute torsion, the testis spose to torsion of the testis, probably by stimulating had a horizontal lie on the affected side, and this anom- the cremaster fibres (Sparks 1971; Anderson and Willi- aly was bilateral in 20%. Jones (1991) found a horizon- amson 1988; Hoshino et al. 1993). However, McCombe tally lying testis in 97%, and a bell-clapper deformity in and Scobie (1988) found no seasonal variation in their 55% of patients. Cass (1982) found a bell-clapper series. deformityin66%andalongmesorchiumin22%of patients with intermittent torsion. Trauma In our meta-analysis of 521 cases of torsion of the testis from ten studies, intermittent subacute torsion A clear history of injury precedes torsion in 4% to 10% I.7 accounted for 23% of all cases. of cases (Anderson and Williamson 1988; Jefferson et al. 1997). Testicular trauma has been a notorious red herring in cases of missed torsion (Cos and Rabinowitz I.7.1.1.5 1982). Severe blunt trauma may cause extravaginal tor- Torsion of Appendages sion in older patients (Kursh 1981). The appendix testis, a Müllerian duct remnant located at the superior pole of the testis, is the most common Exertion appendage to undergo torsion. The epididymal appen- dix, located on the head of the epididymis, is a Wolffian Activities associated with torsion include cycling, duct remnant and may also become twisted. The pre- swimming, parachuting, ice-skating, turning during cise mechanism of torsion of the appendages is not sleep, sexual intercourse, football and rugby. A history clear, but it appears to be mostly restricted to the age of of recent exercise or strenuous activity is reported in pubertyandisusuallyprecededbyvigorousactivityor 7% to 60% of cases (Skoglund et al. 1970a; Anderson trauma. One possible mechanism is that increased oe- and Williamson 1988). strogen stimulation prior to the onset of puberty may cause the vestigial appendage to enlarge and strangu- Sleep late (Skoglund et al. 1970b). Testicular torsion frequently occurs at night, often I.7.1.2 awakingthepatient.Itispossiblytheresultofastrong cremasteric reflex associated with nocturnal erections Aetiology and Pathogenesis (Burgher 1998). Onset of torsion during sleep is re- The prerequisites for intravaginal torsion include an ported in 11% to 40% of cases (Skoglund et al. 1970a; anatomical predisposition for torsion (bell-clapper de- Anderson and Williamson 1988). formity or long mesorchium), an initiating force (cre- masteric spasm) and a poorly understood mechanism Puberty and Hormonal Causes which holds the testis in the torsed position (most probably also cremasteric spasm).
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