Testicular Torsion v Epididymo-Orchitis

A delay in treating torsion is unacceptable. If there is any doubt then surgery must take place to investigate and, if necessary, to untwist the testis.

The testes start as an abdominal organ and move outside of the body two to three weeks prior to birth, bringing all of the structures with them. The structures are condensed into the spermatic cord which leads to the testes. Torsion is when the testes turn on themselves, twisting the cord and impairing the blood supply. This is known as testicular torsion. It is most common in children, adolescents and young men. The symptoms are abdominal pain and, later, testicular pain and tenderness of the testis.

This is different from epididymo-orchitis as the testis is only involved later when the infection spreads there.

The differential diagnosis is epididymo-orchitis. This is an inflammation of the ejaculatory ducts. This causes pain, swelling and tenderness of the testes, malaise and infection. The issue, therefore, is when does epididymo-orchitis become torsion or vice-versa?

The history tells the clinician which is the correct diagnosis. Epididymo-orchitis is common, testicular torsion is not. Epididymo-orchitis responds to antibiotics whereas torsion never does. Epididymo-orchitis can be confirmed by blood tests and urine tests and the patient demonstrates fever and malaise. Testicular torsion can only be confirmed by surgery. Ultrasound scanning does not assist.

The treatment of epididymo-orchitis is rest, fluid and antibiotics. The treatment for torsion is surgery in order to unravel the testis and put in two anchor stitches to hold it in place. The crucial timing is that surgical correction must be made within six hours of the onset of torsion. If so, the testis will usually recover fully. Thereafter, the testis will undergo increasing and permanent damage. To delay by 24 hours will mean that the testis will have died. In young males, this may also have serious implications for their development as they may not be able to complete puberty because of a lack of testosterone. Hormonal studies need to be taken in order to ascertain the extent of the damage. Such an injury also has cosmetic and psychiatric implications.

Torsion is therefore a surgical emergency and requires correction immediately, whatever time of day or night. If there is any doubt, surgery must take place. If, during surgery, it is discovered that the diagnosis is, in fact, epididymo-orchitis then no harm has taken place and the testis will be saved.

Published 26/04/2007.