Testicular Torsion

Presented by:
Stefanie Angeline 04084821719171
Siti Evi Marissa 04054821719116

Supervised by:
dr. H. Marta Hendry, Sp.U, MARS

Surgery Departement
Faculty of Medicine Sriwijaya University- RSUP Dr. Mohammad Hoesin
Palembang
 OUTLINE

Introductio Testicular
Conclusion
n Torsion
 INTRODUCTION

The incidence
Testicular of torsion in
males younger Urological
torsion is a emergency
twisting of than 25 years is
early diagnosis
spermatic cord approximately and treatment are
that causes 4,5 cases per vital to saving the
impaired blood 100.000 men testicle and
flow in the per year preserving future
testes. overall, with fertility.
most age 13-16
years.
Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
Cahya BI. 2015. Perbedaan derajat inflamasi pada tindakan torsi-detorsi testis tikus Sprague Dawley dengan pemberian Phosphodiesterase type 5
inhibitors (http://eprints.undip.ac.id/46688/3/Bagus_Indra_Cahya_22010111120032_lap.kti_bab2.pdf, diakses 02 April 2018).
ANATOMY of TESTIS

Cahya BI. 2015. Perbedaan derajat inflamasi pada tindakan torsi-detorsi testis tikus Sprague Dawley dengan pemberian Phosphodiesterase type 5 inhibitors
(http://eprints.undip.ac.id/46688/3/Bagus_Indra_Cahya_22010111120032_lap.kti_bab2.pdf, diakses 02 April 2018).
Putz R, R Pabst. 2007. Sobotta: Atlas Anatomi Manusia, Edisi 22, Jilid 2. Jakarta: EGC.
Patel A.P. Anatomy and Physiology of Chronic Scrotal Pain. Translational Androgology and Urology. 2017 (6): hal 51-56.
ANATOMY OF TESTIS

Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
Javier G., G. Ciancio. 2014. Vascular Diases of The Testis. 2017. Spinger International Publishing AG.
6
VASCULARIZATION OF TESTIS

Cahya BI. 2015. Perbedaan derajat inflamasi pada tindakan torsi-detorsi testis tikus Sprague Dawley dengan pemberian Phosphodiesterase type 5 inhibitors
(http://eprints.undip.ac.id/46688/3/Bagus_Indra_Cahya_22010111120032_lap.kti_bab2.pdf, diakses 02 April 2018).
Javier G., G. Ciancio. 2014. Vascular Diases of The Testis. 2017. Spinger International Publishing AG.
 INNERVATION OF TESTIS

Patel A.P. Anatomy and Physiology of Chronic Scrotal Pain. Translational Androgology and Urology. 2017 (6): hal 51-56.
8
 Classification of testicular
torsion
a) Intravaginal torsion
b) Extravaginal torsion
c) Torsion due to long messorchium

Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8, diakses pada 03 April 2018).
Patel A.P. Anatomy and Physiology of Chronic Scrotal Pain. Translational Androgology and Urology. 2017 (6): hal 51-56.
 EPIDEMIOLOGY
The incidence of torsion in males younger than 25 years is approximately 4,5
cases per 100.000 men per year overall, with most age 13-16 years.

Extravaginal torsion constitutes approximately 5% of all torsions. Of these

cases of testicular torsion, 70% occur prenatally and 30% occur postnatally.

Intravaginal torsion constitutes approximately 16% of cases in patients

presenting to an emergency department with acute scrotum.

Peak incidence occurs at age 13-14 years. The left testis is more frequently
involved. Bilateral cases account for 2% of all torsions.

Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
Tanto C. 2014. Kapita Selekta Kedokteran, Jilid 1, Edisi 4. Jakarta: Media Aesculapius.
Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8, diakses pada 03 April 2018).
 ETIOLOGI
inadequate
fixation of the
testis and
increased epididymis to
testicular the scrotum or
volume known as ‘bell
(associated clapper
with puberty), deformity’
Idiopathic testicular
tumors, flat-
limbed testes,
4-8 %  or a history of
Trauma cryptoridism.

Cahya BI. 2015. Perbedaan derajat inflamasi pada tindakan torsi-detorsi testis tikus Sprague Dawley dengan pemberian Phosphodiesterase type 5 inhibitors
(http://eprints.undip.ac.id/46688/3/Bagus_Indra_Cahya_22010111120032_lap.kti_bab2.pdf, diakses 02 April 2018).
Tanto C. 2014. Kapita Selekta Kedokteran, Jilid 1, Edisi 4. Jakarta: Media Aesculapius.
Daryanto B, et al. 2010. Pedoman Diagnosis dan Terapi SMF Urologi RSU dr.Saiful Anwar Malang, Fakultas Kedokteran Universitas Brawijaya Malang. (
http://urologimalang.com/?wpfb_dl=18).
Pathophysiology
• Intravaginal torsion
• Extravaginal torsion

12
“ Intravaginal torsion
● High attachment of
the tunica vaginalis
● Abnormal fixation to
the muscle and fascia
coverings of the
spermatic cord
● Testicle can rotate
freely within the
tunica vaginalis
● Bell clapper deformity

Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8).

Shrestha, 2018. SK. Testicular Torsion (http://epomedicine.com/emergency-medicine/testicular-torsion/) 13
Hatch DA. 1996. Failure of Development of Testis Support Structures (http://www.meddean.luc.edu/lumen/meded/urology/bellclap.htm).
 • Neonates
• Not yet descended > attached within
the tunica vaginalis
1
• Inadequate fusion to the scrotal wall
• Typically is diagnosed within the first
7-10 days of life.

Extravaginal torsion
Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8).
Hatch DA. 1996. Failure of Development of Testis Support Structures (http://www.meddean.luc.edu/lumen/meded/urology/bellclap.htm).
 Twisting testicle
Anatomical predisposition + Cremasteric spasm

Twisting of spermatic cord

Impaired venous return

Venous congestion and edema

Arterial ischemia and infarktion

Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8). 15
Sjamsuhidajat R, W de Jong. 2011. Buku Ajar Ilmu Bedah. Jakarta: EGC.
 Clinical ● Swollen, edematous, tender
● Palpable twist or thickening
presentation in cord
● Absent cremasteric reflex
● Newborns: discolored of (40-100%)
scrotum ● Prophetic pain (self-limiting
● Severe acute testicular pain previous episodes)
+/- nausea & vomiting (26- ● Horizontal lie of contralateral
60%) testicle (Angell’s sign; 25-
● History of trauma or 90%)
activities ● Prehn sign’s is absent
● Affected testicle lies high up ● Absent or decreased blood
(Deming’s sign; 26-80%)
Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto. flow on ultrasonography
Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8).
Sharp VJ, Arlen AM. 2013. Testicular Torsion: Diagnosis, Evaluation, and Management . AAFP. 88(12):835-40 (https://www.aafp.org/afp/2013/1215/p835.html) 16
Sjamsuhidajat R, W de Jong. 2011. Buku Ajar Ilmu Bedah. Jakarta: EGC..
 TWIST SCORE
● Testis swelling (2 points)
● Hard testis (2)
● Absent cremasteric reflex
(1)
● EMTs 0-6
● Nausea/vomiting (1)
● Urologist 2-5
● High-riding testis (1)

Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8).
Sharp VJ, Arlen AM. 2013. Testicular Torsion: Diagnosis, Evaluation, and Management . AAFP. 88(12):835-40 (https://www.aafp.org/afp/2013/1215/p835.html) 17
Sjamsuhidajat R, W de Jong. 2011. Buku Ajar Ilmu Bedah. Jakarta: EGC..
 Differential Diagnosis
• Swelling pain tenderness
• Recent viral illness (mumps)
• Erythema to overlying
• Prehn sign positive
Acute skin
• Leukosituria or bacteriuria in
Orchitis • Elevating temperature
urinalysis
• Discharge of pus from the
• History of sexually active
urethra
• Had undergone previous urethral
Acute • Acute scrotal pain
catheterization
• Elevating temperature
Epididymit • Discharge of pus from the
• Prehn sign positive
is • Leukosituria or bacteriuria in
urethra
urinalysis
Incarcerate
d
• History of protussion that able passes through the scrotum.
Purnomo BP. 2012.scrotal
Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
18
Hernia
Sharp VJ, Arlen AM. 2013. Testicular Torsion: Diagnosis, Evaluation, and Management . AAFP. 88(12):835-40 (https://www.aafp.org/afp/2013/1215/p835.html)
Sjamsuhidajat R, W de Jong. 2011. Buku Ajar Ilmu Bedah. Jakarta: EGC..
 Treatment
Non-Operative Operative
Manual detorsion Surgical detorsion
● Rotated in a medial to lateral ● Definitive treatment
direction (open book) 180º Orchiopexy
● Evaluated for pain relief ● Testis is anchored to the
● Consider opposite direction scrotal wall
● Objective evaluation using Orchiectomy
USG Doppler ● Perform if testicle is not
viable
Purnomo BP. 2012. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto.
Sharp VJ, Arlen AM. 2013. Testicular Torsion: Diagnosis, Evaluation, and Management . AAFP. 88(12):835-40 (https://www.aafp.org/afp/2013/1215/p835.html)
19
Ogunyemi O, ED Kim. 2015. Testicular Torsion (http://emedicine.medscape.com/article/2036003-overview#a8).
Complication
● Testicular Atrophy
● Testicular infarction
● Infection
● Infertility due to the loss of the testicle
● Cosmetical problems

20
Prognosis
12-24
hours
20-50%

GOLDEN TIME
<6 hours
90-100%
>24 hours success rate
0-10%

21
Thanks!
Any questions?

22