What Are Testes?
Testicles or testes are an integral part of the male reproductive system. They are paired oval-shaped structures that form before birth. Normally, the testicles remain in the body during development. However, before the baby is born, they slide into a pouch-like structure known as the scrotum. So, the testicles are normally present outside the body in the scrotum. Testicles require a temperature of 4 to 5 degrees lower than the normal body temperature for the formation of sperm. Therefore, they lie within the scrotum because spermatogenesis is impossible inside the body and at a high temperature. Testicles also release hormones that are required for the male's sexual growth and development.
What Is Testicular Torsion?
As the name suggests, testicular torsion is a condition when the testicles twist or rotate, or change their position. A tuft of blood vessels known as the spermatic cord is present around the testis. The main function of this spermatic cord is to supply blood to the testis. When the testis gets torsed, the spermatic cord gets twisted. As a result, the blood supply of the testis is lost, resulting in sudden severe pain and swelling. Testicular torsion is commonly seen in young individuals between 12 to 18 years, but it might occur at any age. Sometimes, testicular torsion might occur even before birth. Testicular torsion is a medical emergency and requires intensive medical care and attention. If the condition is treated without delay, the testicles can be saved. Otherwise, the blood supply might get cut off for a long time, and the testis becomes damaged to the extent that it must be removed.
What Are the Causes of Testicular Torsion?
Testicular torsion is a condition when the testicles rotate around the spermatic cord. The main job of the spermatic cord is to supply blood to the testicles from the abdomen. If the testicles change their positions, the blood supply becomes blocked, and the testicles get damaged. The exact cause of testicular torsion is still under research. Studies have reported that males who suffer from testicular torsion have a hereditary factor that allows the free movement of the testicles. Testicular torsion might occur a few hours after vigorous activity, minor injuries, and during sleep. Winters and the growth of the testicles during puberty might be the reasons for testicular torsion. The factors that increase the risk of testicular torsion are listed below:
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Age - Testicular torsion is commonly seen in males 12 to 18 years of age.
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Previous Testicular Torsion - If the patient experienced testicular pain previously that subsided without any treatment, testicular torsion is more likely to occur. The more the severity of the pain, the greater the risk of testicular damage.
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Family History - The condition might be present in the other family members.
What Are the Signs and Symptoms of Testicular Torsion?
Testicular torsion is a common condition and scrotal pain at night or anytime during the day is the most typical symptom. The other signs and symptoms of testicular torsion are listed below:
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Sudden and severe scrotal pain.
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Scrotal swelling.
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Abdominal pain.
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Fever, nausea, and vomiting.
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Unusual positioning of the testis.
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Urinary frequency.
What Are the Indications of Manual Detorsion of Testes?
Patients suffering from testicular torsion usually present with unilateral and severe scrotal pain. Some patients might have a medical history of testicular pain resolved after testicular detorsion. The following causes of scrotal pain must be ruled out before going for manual testicular detorsion:
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Orchitis (inflammation of the testicles).
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Epididymitis (inflammation of the coiled tube present behind the testicles).
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Trauma.
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Hydrocele (accumulation of fluids due to inflammation in the scrotum).
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A testicular tumor (tumor of the testes).
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Idiopathic scrotal edema (swelling of the scrotum).
What Are the Contraindications of Manual Testicular Detorsion?
In older males, the characteristic feature of testicular detorsion is the sudden onset of pain in the scrotum and severe testicular pain. Pain is often accompanied by scrotal or inguinal swelling, but the pain becomes less when the necrosis is complete. The contraindications of testicular detorsion are listed below:
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Manual testicular detorsion is not recommended when the testicular torsion lasts for more than six to eight hours. It is because when the testicles remain devoid of the blood supply for prolonged periods, they swell, and manual detorsion is not possible.
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Manual detorsion should not be done if it delays scrotal exploration and the surgical removal of undescended testicles (orchiopexy).
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Testicular detorsion should only be done in cases of acute testicular torsion because, in chronic or long-standing conditions, this procedure does not provide any benefit.
How Is the Procedure of Manual Testicular Detorsion Done?
Manual testicular detorsion is not carried out under general or local anesthesia. However, analgesic medications might be administered after the testicular torsion is diagnosed. The patient might not require any special equipment before the procedure. However, the doctor might recommend a Doppler ultrasound before the procedure to evaluate the blood flow to the testis. The Doppler ultrasound procedure is explained below:
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Doppler Ultrasound - During a Doppler ultrasound, the doctor applies a gel over the patient’s abdomen and asks him to lie down on the X-ray table. Next, he moves a transducer over the patient’s abdomen to send sound waves into the body. These waves reflect back and produce images on the computer screen. Unlike normal ultrasound, the Doppler ultrasound also shows images of the blood vessels and helps evaluate the organs' blood supply.
The patient remains in the supine or standing position during the procedure. In patients suffering from testicular torsion, the affected testicle is torsed or twisted inwards. For example, if the left testicle is to be detorsed, hold it with the right thumb and the forefinger and rotate it around 180 degrees. This procedure needs to be repeated two to three times because a testicular torsion might involve a rotation of 180 to 720 degrees. Ensure the pain resolves with each movement and the testicles return to their normal anatomic position. If the detorsion of the right testicle is to be done, the doctor needs to follow a similar procedure. The only difference being the testicle is held between the left thumb and the forefinger and rotated in a counterclockwise direction.
Studies have reported that manual detorsion is successful in 30 to 70 % of patients as they get immediate relief from scrotal pain and discomfort. However, some researchers believe that a doppler ultrasound must be done before and after the procedure to confirm the re-establishment of the blood flow.
How Can One Know About the Success of Manual Testicular Detorsion?
Manual testicular detorsion is a simple procedure, but the following factors determine its success:
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The pain must subside immediately after the procedure.
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The testicles return back to their original position after the procedure.
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Return of the cremaster reflex (when the thigh is stroked, the reflex returns to normal).
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Doppler ultrasound shows the re-establishment of blood flow.
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The testicles are in a lower position in the scrotum.
Conclusion:
Manual testicular detorsion is a simple procedure, and the patient does not experience any surgical trauma. Testicular torsion might cause severe complications if left untreated for a long time. As the procedure is not carried out under anesthesia, the patient remains aware of his surroundings. However, testicular detorsion cannot be done in every case of testicular pain. Before doing the procedure, other causes of testicular pain must be ruled out because every time, the pain does not need to be due to testicular torsion. Doctors prefer the procedure because of its high success rates. But the important point to be aware of is that the procedure must be carried out in an expert’s hands. Consult a urologist before undergoing a manual testicular detorsion to know about the benefits and risks.
