Testicular torsion

Disease Description (Causes and Symptoms)

• Definition: Testicular torsion is an emergency condition in which the spermatic cord twists, blocking arterial blood flow to the testis and potentially causing ischemia (impaired blood flow) and necrosis. Rapid diagnosis and treatment determine the prognosis.
• Causes and pathophysiology: The testis can rotate freely and twist the spermatic cord due to congenital abnormalities (e.g., bell-clapper deformity), undescended testis, or a horizontal testicular position. Trauma, strenuous exercise, or sudden changes in body position may trigger it.
• Main symptoms: Sudden, severe scrotal (testicular) pain, swelling and redness of the scrotum, elevation or horizontal positioning of one testis, lower abdominal pain, nausea and vomiting, and possibly urinary frequency or fever. The time when the pain began (onset time) is important for prioritizing diagnosis and treatment.

Treatment Methods

• Emergency principle: Because testicular ischemia progresses, suspected cases require immediate emergency urological care (with preparation for surgery), and surgery should not be delayed for diagnostic testing.
• Nonsurgical treatment: If attempted by an experienced physician, manual detorsion may be performed (generally by rotating the testis outward). Even if successful, surgical fixation (orchiopexy) must subsequently be performed.
• Surgical treatment (standard treatment): After emergency exploration (exploratory incision), the testis is untwisted and recovery of blood flow is confirmed, followed by fixation of both testes (bilateral orchiopexy). If necrosis has already progressed and recovery is impossible, the affected testis is removed (orchiectomy).
• Diagnostic adjunctive tests: Color Doppler ultrasonography is useful for assessing blood flow, but surgery must not be delayed because of the test. Nuclear medicine testing is also possible, but emergency surgery takes priority.
• Medication and pain management: Completely masking symptoms with strong pain medication before diagnosis may interfere with diagnosis, so prescriptions are determined according to the diagnostic situation. Pain management and antibiotics before and after surgery may be used depending on the clinical situation.
• Precautions/complication risks/self-care:
  • The longer the time after pain begins, the more rapidly the testicular salvage rate decreases (generally, the recovery rate is highest when treatment is provided within 6 hours; the salvage rate decreases after 12 hours).
  • Delayed treatment may result in testicular necrosis → removal, reduced future fertility (sperm production) or risk of infertility, infection, and wound complications.
  • Even if fixation was performed after surgery, bilateral fixation is necessary, so care of the opposite testis is also important.
  • During recovery, avoid strenuous exercise and lifting heavy objects; use of scrotal support is recommended.

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items/documents to bring:
  • Record the time symptoms began (the exact time)
  • Characteristics of the pain (onset, continuous or intermittent, intensity) and accompanying symptoms (nausea, vomiting, fever, etc.)
  • List of medications currently being taken (including anticoagulants) and history of allergies
  • Previous surgical history (scrotal/groin surgery, orchiopexy, etc.) and whether congenital abnormalities (undescended testis) are present
  • Bring previous ultrasound or test results if available (photos if possible)
  • If possible, a photograph of the scrotum (its appearance immediately after symptoms began)
• Information to tell the doctor in advance at the outpatient visit:
  • The time the pain began (in hours)
  • The location of the pain (left/right), changes in the shape of the scrotum, and whether vomiting occurred
  • Whether there was recent trauma or strenuous exercise
• Example questions (questions for the patient to write down and bring):
  • When did the pain begin?
  • Is the pain on one side or both sides?
  • Did you have nausea, vomiting, or fever along with the pain?

General Example Questions to Ask the Doctor

• "Given my symptoms right now, how likely is it that the testis can be saved?"
• "If surgery is needed, what surgical method will be used and how long will recovery take?"
• "What effects could the surgery have on future fertility (sperm function) and sexual function?"
• "What medications or lifestyle habits should I be careful about before and after surgery (e.g., anticoagulants and exercise restrictions)?"

Example Disease-Specific Questions

• "If I tell you exactly how many hours have passed since the pain began, how likely is it that the testis can be saved?"
• "If the testis has to be removed, should I consider preserving future fertility (such as sperm freezing)?"