Trauma induced testicular torsion is a well recognised entity, the incidence being 4–8% in most studies reporting on testicular torsion. The signs and symptoms of testicular torsion may easily be mistakenly attributed to preceeding testicular trauma if there was such an event. A patient is described with trauma induced testicular torsion who presented on three occasions before a decision was made to perform scrotal exploration. Unfortunately, an orchidectomy was the outcome. The message that trauma can and not infrequently does precipitate torsion, needs to be reiterated. Awareness of the entity and constant vigilance is required of clinicians to avoid a delay in definitive treatment.
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The incidence of testicular torsion has been rising1–3 but this has been mirrored by a rise in the testicular salvage rate.1, 3 Barker and Raper in 1964 reviewed the literature and found the immediate testicular salvage rate to be 10% and reported a salvage rate of 29% in their own series.4 Reports in the 1970s and 1980s, taking delayed testicular atrophy into account, reported testicular salvage rates from 42–79%.1–3, 5–8 This improvement was attributed to an increasing awareness of the condition among the general practitioners and hospital doctors, leading to an increased and an earlier diagnosis.3, 7 A willingness to explore immediately where there is doubt has also contributed to the improved salvage rate.6 In the 1990s, Daehlin et al9 reported a testicular salvage rate of 56% after a 4–10.5 year follow up.
Trauma induced testicular torsion is now a well recognised entity, the incidence being 4–8% of testicular torsion in most series1, 3, 10, 11 with the highest reported incidence being 12%.12 The reports that have commented on the testicular salvage rate in trauma induced testicular torsion are largely in the form of case reports and contain small numbers of patients. The testicular salvage rate reported in trauma induced testicular torsion has been variable (0%,10, 13, 14 33%,15 80%11 and 100%16). The scrotal and testicular symptoms and signs of trauma induced testicular torsion may be mistakenly attributed to the trauma itself. A case of trauma induced testicular torsion, initially diagnosed as a traumatic scrotal haematoma, is reported to serve as a reminder and to promote an awareness of the entity.
Somersaulting off a springboard, the perineum and the scrotum of a 14 year old boy were the parts of the body to first hit the water in the swimming pool. He presented for medical attention a few hours later when the pain did not resolve. At the medical examination, a tender right scrotal swelling was noted and a diagnosis of a traumatic scrotal haematoma was made and he was discharged with analgesics.
He presented for medical attention two days later and was again discharged with a similar diagnosis. He presented a third time, five days after his initial injury because of worsening of his pain and swelling. On physical examination, the scrotum was markedly swollen and indurated, with the scrotal skin taut. A diagnosis of traumatic scrotal haematoma was made by the duty surgeon, and a decision was made to explore the scrotum to evacuate the haematoma for the relief of the symptoms.
At scrotal exploration, the right testicle was found to be gangrenous secondary to torsion of the spermatic cord. A moderate amount of scrotal haematoma was also present and this was evacuated. A right orchidectomy was performed. Orchidopexy of the left testis was performed. Postoperative recovery was uneventful and he was discharged on the second postoperative day.
The most important risk factor for testicular torsion is an anatomical predisposition, the commonest being a high or a complete investment of the testicle and the spermatic cord (bell clapper deformity) by the tunica vaginalis.3, 4, 17, 18 The cremasteric muscle surrounds the spermatic cord in a spiral manner and contraction of this muscle has a rotational effect on the testicle. A strong contraction of this muscle can therefore rotate a predisposed, freely mobile testicle, which may go on to undergo torsion.11, 19
The combination of reports on trauma induced testicular torsion10, 11, 13–16 with this case report gives an overall testicular salvage rate of 40% (6 of 15) in trauma induced testicular torsion in the medical literature. It may be very difficult at times to distinguish clinically, torsion and an acute injury. These patients must be referred immediately to an urologist or a general surgeon where an assessment can be made and further investigations or immediate surgical exploration performed as necessary. Where there is a high clinical suspicion of testicular torsion, further investigations are unnecessary and immediate surgical exploration is warranted.23 However, where physical examination is equivocal, colour Doppler ultrasonography or scintigraphy may be helpful in establishing the diagnosis.23–25
The immediate testicular survival rate and the subsequent testicular atrophy and impairment in testicular function are directly related to the duration and the degree of the torsion.1, 3, 6–9, 18, 20, 21 Only 4% of testis are found to be non-viable in acute torsion of less than 12 hours duration compared with a 75% infarction rate if the history was greater than 12 hours.3 Time therefore is of the greatest essence if the testis is to be saved. Recent reports suggest that most delays to testicular exploration occur because of late presentation to the hospital.5, 10, 22 In this reported case, there was not only a delay in presentation but the patient was also then discharged on two occasions when the diagnosis of traumatic scrotal haematoma was assumed because of the history of trauma.
We feel that a clear message that trauma can precipitate torsion needs to be reiterated. A high index of suspicion is required of the examining clinician. It is all too easy to attribute the testicular pain, swelling and induration as secondary to testicular trauma. Clinicians should always attempt to think and look beyond the obvious.
Yeap Joo Seng performed the literature review, discussed and outlined the core aspects of the case report and participated in the writing of the paper. Kevin Moissinac was the duty surgeon who performed the surgical exploration, initiated the case report, participated in the literature review and the writing of the paper. Kevin Moissinac will act as guarantor.
Conflicts of interest: none.