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Torsion of the Spermatic Cord and Torsion of the Hydatid Testis
Torsion of the Spermatic Cord and Torsion of the Hydatid Testis VINCENT J. O'CONOR, M.D. *
A SWELLING or enlargement of the scrotal content usually brings the patient to his physician promptly. A mother rarely wastes any time in notifying the family physician that her infant son has developed "a swollen testicle." The scrotal swellings which are most commonly diagnosed incorrectly are those due to torsion of the spermatic cord (often wrongly spoken of as lttorsion of the testicle") and the much less common condition of torsion of the hydatid testis. Almost invariably the pediatrician or general physician who sees these patients first will make a diagnosis of epididymitis or orchitis as the cause of scrotal enlargement. This article is written in the hope that those who read it will become acutely aware of the frequ~ncy of torsion of the spermatic cord and will thereafter make an accurate diagnosis at an early stage of the condition so that proper treatment will result in conservation of testicular tissue and function. Let us first emphasize the fact that true orchitis is very rare. It is seen only as a complication of epidemic parotitis (mumps) or secondary to a generalized body infection, such as septicemia. Secondary orchitis may occur only as an adjunct feature of severe epididymitis. TORSION OF THE SPERMATIC CORD
This condition is an axial rotation or twisting of the cord upon itself, with a sudden, or gradual, constriction of the blood supply to the testicle, epididymis and investing structures. If it is unrelieved, testicular lysis or atrophy will result. The epididymis survives the loss of its blood supply and is usually normal to palpation when the testis, as such, has completely disappeared. From the Department of Urology of Chicago Wesley Memorial Hospital and Northwestern University Aiedical School, Chicago, Illinois.
* Professor of Urology and Chairman of the Department, Northwestern Untiversity M ed1~cal School and Chicago Wesley M emorial Hospital. 1781
1732
Vincent J. O'Conor
Incidence
Nearly a thousand instances of torsion of the spermatic cord have been recorded in the literature, and more than 20 per cent of these occurred during the first decade of life. The average age in all cases has been said to be about 14 years, but torsion has been correctly diagnosed in the newborn and operated upon during the first day of life. Torsion has occurred more frequently on the left than on the right (3 to 2). Bilateral involvement is occasionally noted. The true incidence is unknown, since the majority of cases are not correctly diagnosed, and those that are recognized accurately are rarely reported. There can be no doubt that it is of common occurrence. Those physicians who perform routine physical examinations of applicants for insurance or employment have noted large numbers of men with unilateral testicular atrophy or palpable absence of the testis, with a normal-sized cord and epididymis. This condition is undoubtedly the aftermath of torsion of the corresponding spermatic cord. Two clearly defined varieties of torsion of the spermatic cord occur: the acute and the recurrent. The acute type should be readily recognized because it is of sudden onset, becomes progressively more painful and ultimately brings the patient to surgery. The recurrent type may very easily go unrecognized, the diagnosis of orchitis or epididymitis being made. During a subsequent attack, which does not quiet down so readily, the correct diagnosis may be made. Etiology
Torsion may occur at any age. We have seen it in a day old infant and in a man 78 years of age. Torsion is noted somewhat more often in the undescended testis than in the normally placed one. Torsion may occur in the cord of an abdominal testis. We have correctly diagnosed this condition on one occasion. In our opinion, torsion is always brought about by contraction of the cremasteric fibers. As a rule, there must be an abnormal attachment of the testis and a certain deficiency in make-up of the gubernaculum associated with a more or less capacious tunica vaginalis. This anatomic variation would not result in torsion; the twist itself results from repeated contraction of cremasteric muscle bundles. These muscular strands may be anomalous or accessory. Therefore, the degree of torsion, i.e., the number of half-turns or full-turns the cord undergoes, depends indirectly upon the freedom of the testicle to be rotated inside the tunica and directly upon the strength of the contraction of the cremasteric fibers. Torsion most commonly comes about during sleep or when the person is relaxed. However, in many instances physical strain, rapid walking, coughing, crossing the legs, etc., has immediately preceded the onset of
Torsion of the Spermatic Cord and of the Hydatid Testis
1733
torsion. Gradual and repeated strain has been noted more often in recurrent torsion, as during coitus or defecation. Pathology
The cord above the torsion contains dilated, flattened or partially obliterated spermatic veins, depending upon the extent of their occlusion in the twist. The spermatic artery is always greatly dilated, but usually pervious. In an acute t,vist, the surrounding tissue is edematous; in a recurrent twist, it is adherent and fibrous. In the acute cases, the twist occurs from without inward about twothirds of the time. In the recurrent cases, no rule can be formulated. The extent of the twist varies from a one-half turn to two full turns, and the site of the t,vist is always in that free portion of the cord which, covered by tunica vaginnJis, suspends the epididymis and testicle. Incision into the tunica vaginnJis reveals more or less blood-stained fluid in the early stages, but in the longer-standing process it is entirely filled with old blood clot. The remainder of the cord below the twist, including the epididymis, is greatly s,vollen and bluish or purplish, in color, and the spiral intersections produced by the t,vist are clearly scene The testis may be only slightly enlarged, or it may be enormously distended. On section, the parts show intense engorgement, red, blue or black, depending on the duration of obstruction. In the longer-standing cases, there is a destruction of the testis, not a necrosis in the ordinary sense of the word, but an aseptic death of the gland, which, in turn, undergoes fibrification and consequent atrophy if left in the scrotum. In the recurrent cases, any sharper attack than usual may cause lymph to be deposited in the tunica vaginalis and adhesions may form, anchoring the testicle. Microscopically, one may see hemorrhagic infarction; there may be no organ left, but merely old blood clot, or a diffuse interlobular hemorrhage. Symptoms
Most patients experience a sudden, excruciating pain in the testicular region, follo,ved by extreme tenderness. The pain is localized within the scrotum, but is usually referred upward along the cord and lower abdominal region of the affected side. The testicle is very tender to palpation, and is drawn upward in the scrotum toward the external abdominal ring. The epididymis may be felt anterior or lateral to the testicle instead of in its customary posterior position. Within a short time after the onset, edema and hyperemia of the scrotal skin appear. Subsequently, there is a gradual swelling of the scrotal contents and fluid forms in the tunica vaginalis. Swelling ceases to increase in 48 to 72 hours; by this time the outline of the testis and epididymis becomes
1734
Vincent J. O'Conor
obscured, but the swelling still has the appearance of being drawn upward in the scrotum or inguinal canal because of the shortening produced by the torsion. Nausea and vomiting frequently follow the onset of pain, and in very acute cases a general weakness and malaise are present. There is very slight general reaction in the majority of cases, and the temperature, pulse and leukocyte count are not in proportion to the severity of the local condition. If no attempt is made, either manually or by open operation, to untwist the cord, there is usually a slight subsidence of all pain after a week or ten days, but the swelling and a local tenderness usually persist longer. In a small percentage of cases, gangrene eventually sets in. The usual sequel is a marked atrophy due to fibrotic changes in the testicle. Diagnosis
Epididymitis should be ruled out by the absence of any history of previous prostatic or urinary infection or of recent urethral instrumentation. Urinary findings in torsion are normal. Rectal palpation of the prostate and seminal vesicles indicates no abnormality. Orchitis is differentiated by the absence of mumps or generalized infection, the character of the swelling, the high position of the testis and the involvement of the cord. Idiopathic hydrocele, fibroma of the cord, neoplasm of the testis, ruptured varicocele with scrotal hematoma, and lymphadenitis of the horizontal chain of glands can all be readily diagnosed by careful examination. The most difficult condition to exclude is a strangulated inguinal hernia or an incarcerated omental hernia. If the testis is absent from the scrotum, the former conditions can be ruled out very easily, but the differentiation from hernia is more difficult. A coincident Richter's hernia is extremely misleading in diagnosis of torsion. The redness of the scrotum, the elevation of the testis and the limitation of swelling to the lower portion of the inguinal canal are the all-important local findings. In case of doubt, immediate surgical exploration will often clarify the situation. There are a sufficient number of reports describing torsion of the spermatic cord in intra-abdominal testes, with symptoms simulating appendicitis, to remind one that the absence of a testis in the scrotum or groin should suggest the possibility of torsion, with acute abdominal distress. Prognosis
In recurring torsion, the attacks will continue and will almost invariably result in a varying degree of atrophy accompanied by neuralgic pain unless an orchidopexy is performed. Some patients have had no
Torsion of the Spermatic Cord and of the Hydatid Testis
1735
recurrence after the first manipulation to untwist the cord, but these are always patients seen in the early part of the first attack. In acute torsion with marked symptoms, there is usually no relief for a long time except by successful manipulation or operative interference. No fatal result in torsion has been recorded. Loss of testicular tissue and, of course, function, is the invariable sequel when treatment has not been promptly applied. Treatment Detorsion should always be attempted in patients seen early, but only in those in whom the testis is below the external abdominal ring. Manipulative success is obviously impossible when the strangulation has existed long enough for engorgement of the testis to have occurred or for much fluid to have accumulated in the tunica vaginalis. Detorsion is accomplished by grasping the testicle between the thumb and second finger and slowly rotating it on the vertical axis, first trying from within outward, as the torsion most often occurs in a counterclockwise direction. No force should be used and torsion should be continued until relief is felt or pain and resistance become so severe that it is obviously being twisted in the wrong direction. As a rule, one should advise an orchidopexy as soon as possible after a successful detorsion has been done. It is always unwise to attempt detorsion in a case of undescended testis; because of the impossibility of ruling out coincident hernia, operative interference is always immediately indicated in these patients. Orchidopexy should be performed immediately when successful detorsion has been accomplished surgically and it is deemed advisable to save the testis. The usual transposition can be done on undescended testes with satisfactory results. In fully-descended testes, any operation that accomplishes shortening of the gubernaculum, with fixation, will achieve success. Simple eversion and suture of the tunica vaginalis is usually sufficient. Orchidectomy. In an adult, when transposition of the undescended testis cannot be satisfactorily accomplished, or in any case in which necrosis, gangrene or persistent circulatory obstruction is present, removal of the testicle and the involved portion of the cord is indicated. Successful surgical detorsion and orchidopexy in acute torsion must be performed in the first few hours after the onset of pain and swelling, or the circulatory damage will be so great that orchidectomy will be necessary. In many patients, because of the frequency of bilateral abnormality, it is imperative to carry out a prophylactic orchidopexy on the opposite side. If there is any question as to the diagnosis, one should err on the side of safety, explore the mass in question and not chance the loss of a testicle. The condition is important enough even to justify exploration
Vincent J. O'Conor
1736
of an acute epididymitis, if this has not been ruled out. Operation, of course, is necessary in all patients in whom strangulated hernia has been mistaken for torsion. If the diagnosis has been missed for several days, and the pain is diminishing without persistent fever, nausea or vomiting, conservative treatment of bed rest, scrotal elevation and hot or cold applications will be the treatment of choice. The end result will be an aseptic necrosis with complete disappearance of the body of the testis. TORSION OF THE APPENDIX TESTIS
The appendix testis, sometimes referred to as the hydatid of Morgagni, is a small, pedunculated, ovoid structure attached to the tunica albuginea propria in juxtaposition to the globus major of the epididymis. Torsion of this structure is of infrequent occurrence and is most frequently seen in prepubertal boys, although ,ve have correctly diagnosed the condition several times in young adults. The symptoms are somewhat similar to those seen in torsion of the spermatic cord, but the pain is usually less severe and there are rarely any constitutional symptoms such as fever or nausea. As in torsion, a secondary hydrocele may develop rather quickly and may interfere with the palpatory findings necessary for an accurate diagnosis. When a small pea-sized mass is palpated distinct from the testis near the upper pole, accompanied by local tenderness, and slight overlying redness and edema of the scrotum occur, the diagnosis should be evident. Spermatocele is the most common condition to be confused on palpation. It is a chronic condition, is rarely tender and is without circulatory effect upon the scrotal skin. Recurrent epididymitis is also an easily confused condition. Treatment consists of surgical excision of the small, pedunculated, edematous and sometimes gangrenous mass. Eversion and suture of the tunica vaginalis should also be done to prevent subsequent hydrocele formation. 720 N. Michigan Boulevard Chicago 11, Illinois
A SWELLING or enlargement of the scrotal content usually brings the patient to his physician promptly. A mother rarely wastes any time in notifying the family physician that her infant son has developed "a swollen testicle." The scrotal swellings which are most commonly diagnosed incorrectly are those due to torsion of the spermatic cord (often wrongly spoken of as lttorsion of the testicle") and the much less common condition of torsion of the hydatid testis. Almost invariably the pediatrician or general physician who sees these patients first will make a diagnosis of epididymitis or orchitis as the cause of scrotal enlargement. This article is written in the hope that those who read it will become acutely aware of the frequ~ncy of torsion of the spermatic cord and will thereafter make an accurate diagnosis at an early stage of the condition so that proper treatment will result in conservation of testicular tissue and function. Let us first emphasize the fact that true orchitis is very rare. It is seen only as a complication of epidemic parotitis (mumps) or secondary to a generalized body infection, such as septicemia. Secondary orchitis may occur only as an adjunct feature of severe epididymitis. TORSION OF THE SPERMATIC CORD
This condition is an axial rotation or twisting of the cord upon itself, with a sudden, or gradual, constriction of the blood supply to the testicle, epididymis and investing structures. If it is unrelieved, testicular lysis or atrophy will result. The epididymis survives the loss of its blood supply and is usually normal to palpation when the testis, as such, has completely disappeared. From the Department of Urology of Chicago Wesley Memorial Hospital and Northwestern University Aiedical School, Chicago, Illinois.
* Professor of Urology and Chairman of the Department, Northwestern Untiversity M ed1~cal School and Chicago Wesley M emorial Hospital. 1781
1732
Vincent J. O'Conor
Incidence
Nearly a thousand instances of torsion of the spermatic cord have been recorded in the literature, and more than 20 per cent of these occurred during the first decade of life. The average age in all cases has been said to be about 14 years, but torsion has been correctly diagnosed in the newborn and operated upon during the first day of life. Torsion has occurred more frequently on the left than on the right (3 to 2). Bilateral involvement is occasionally noted. The true incidence is unknown, since the majority of cases are not correctly diagnosed, and those that are recognized accurately are rarely reported. There can be no doubt that it is of common occurrence. Those physicians who perform routine physical examinations of applicants for insurance or employment have noted large numbers of men with unilateral testicular atrophy or palpable absence of the testis, with a normal-sized cord and epididymis. This condition is undoubtedly the aftermath of torsion of the corresponding spermatic cord. Two clearly defined varieties of torsion of the spermatic cord occur: the acute and the recurrent. The acute type should be readily recognized because it is of sudden onset, becomes progressively more painful and ultimately brings the patient to surgery. The recurrent type may very easily go unrecognized, the diagnosis of orchitis or epididymitis being made. During a subsequent attack, which does not quiet down so readily, the correct diagnosis may be made. Etiology
Torsion may occur at any age. We have seen it in a day old infant and in a man 78 years of age. Torsion is noted somewhat more often in the undescended testis than in the normally placed one. Torsion may occur in the cord of an abdominal testis. We have correctly diagnosed this condition on one occasion. In our opinion, torsion is always brought about by contraction of the cremasteric fibers. As a rule, there must be an abnormal attachment of the testis and a certain deficiency in make-up of the gubernaculum associated with a more or less capacious tunica vaginalis. This anatomic variation would not result in torsion; the twist itself results from repeated contraction of cremasteric muscle bundles. These muscular strands may be anomalous or accessory. Therefore, the degree of torsion, i.e., the number of half-turns or full-turns the cord undergoes, depends indirectly upon the freedom of the testicle to be rotated inside the tunica and directly upon the strength of the contraction of the cremasteric fibers. Torsion most commonly comes about during sleep or when the person is relaxed. However, in many instances physical strain, rapid walking, coughing, crossing the legs, etc., has immediately preceded the onset of
Torsion of the Spermatic Cord and of the Hydatid Testis
1733
torsion. Gradual and repeated strain has been noted more often in recurrent torsion, as during coitus or defecation. Pathology
The cord above the torsion contains dilated, flattened or partially obliterated spermatic veins, depending upon the extent of their occlusion in the twist. The spermatic artery is always greatly dilated, but usually pervious. In an acute t,vist, the surrounding tissue is edematous; in a recurrent twist, it is adherent and fibrous. In the acute cases, the twist occurs from without inward about twothirds of the time. In the recurrent cases, no rule can be formulated. The extent of the twist varies from a one-half turn to two full turns, and the site of the t,vist is always in that free portion of the cord which, covered by tunica vaginnJis, suspends the epididymis and testicle. Incision into the tunica vaginnJis reveals more or less blood-stained fluid in the early stages, but in the longer-standing process it is entirely filled with old blood clot. The remainder of the cord below the twist, including the epididymis, is greatly s,vollen and bluish or purplish, in color, and the spiral intersections produced by the t,vist are clearly scene The testis may be only slightly enlarged, or it may be enormously distended. On section, the parts show intense engorgement, red, blue or black, depending on the duration of obstruction. In the longer-standing cases, there is a destruction of the testis, not a necrosis in the ordinary sense of the word, but an aseptic death of the gland, which, in turn, undergoes fibrification and consequent atrophy if left in the scrotum. In the recurrent cases, any sharper attack than usual may cause lymph to be deposited in the tunica vaginalis and adhesions may form, anchoring the testicle. Microscopically, one may see hemorrhagic infarction; there may be no organ left, but merely old blood clot, or a diffuse interlobular hemorrhage. Symptoms
Most patients experience a sudden, excruciating pain in the testicular region, follo,ved by extreme tenderness. The pain is localized within the scrotum, but is usually referred upward along the cord and lower abdominal region of the affected side. The testicle is very tender to palpation, and is drawn upward in the scrotum toward the external abdominal ring. The epididymis may be felt anterior or lateral to the testicle instead of in its customary posterior position. Within a short time after the onset, edema and hyperemia of the scrotal skin appear. Subsequently, there is a gradual swelling of the scrotal contents and fluid forms in the tunica vaginalis. Swelling ceases to increase in 48 to 72 hours; by this time the outline of the testis and epididymis becomes
1734
Vincent J. O'Conor
obscured, but the swelling still has the appearance of being drawn upward in the scrotum or inguinal canal because of the shortening produced by the torsion. Nausea and vomiting frequently follow the onset of pain, and in very acute cases a general weakness and malaise are present. There is very slight general reaction in the majority of cases, and the temperature, pulse and leukocyte count are not in proportion to the severity of the local condition. If no attempt is made, either manually or by open operation, to untwist the cord, there is usually a slight subsidence of all pain after a week or ten days, but the swelling and a local tenderness usually persist longer. In a small percentage of cases, gangrene eventually sets in. The usual sequel is a marked atrophy due to fibrotic changes in the testicle. Diagnosis
Epididymitis should be ruled out by the absence of any history of previous prostatic or urinary infection or of recent urethral instrumentation. Urinary findings in torsion are normal. Rectal palpation of the prostate and seminal vesicles indicates no abnormality. Orchitis is differentiated by the absence of mumps or generalized infection, the character of the swelling, the high position of the testis and the involvement of the cord. Idiopathic hydrocele, fibroma of the cord, neoplasm of the testis, ruptured varicocele with scrotal hematoma, and lymphadenitis of the horizontal chain of glands can all be readily diagnosed by careful examination. The most difficult condition to exclude is a strangulated inguinal hernia or an incarcerated omental hernia. If the testis is absent from the scrotum, the former conditions can be ruled out very easily, but the differentiation from hernia is more difficult. A coincident Richter's hernia is extremely misleading in diagnosis of torsion. The redness of the scrotum, the elevation of the testis and the limitation of swelling to the lower portion of the inguinal canal are the all-important local findings. In case of doubt, immediate surgical exploration will often clarify the situation. There are a sufficient number of reports describing torsion of the spermatic cord in intra-abdominal testes, with symptoms simulating appendicitis, to remind one that the absence of a testis in the scrotum or groin should suggest the possibility of torsion, with acute abdominal distress. Prognosis
In recurring torsion, the attacks will continue and will almost invariably result in a varying degree of atrophy accompanied by neuralgic pain unless an orchidopexy is performed. Some patients have had no
Torsion of the Spermatic Cord and of the Hydatid Testis
1735
recurrence after the first manipulation to untwist the cord, but these are always patients seen in the early part of the first attack. In acute torsion with marked symptoms, there is usually no relief for a long time except by successful manipulation or operative interference. No fatal result in torsion has been recorded. Loss of testicular tissue and, of course, function, is the invariable sequel when treatment has not been promptly applied. Treatment Detorsion should always be attempted in patients seen early, but only in those in whom the testis is below the external abdominal ring. Manipulative success is obviously impossible when the strangulation has existed long enough for engorgement of the testis to have occurred or for much fluid to have accumulated in the tunica vaginalis. Detorsion is accomplished by grasping the testicle between the thumb and second finger and slowly rotating it on the vertical axis, first trying from within outward, as the torsion most often occurs in a counterclockwise direction. No force should be used and torsion should be continued until relief is felt or pain and resistance become so severe that it is obviously being twisted in the wrong direction. As a rule, one should advise an orchidopexy as soon as possible after a successful detorsion has been done. It is always unwise to attempt detorsion in a case of undescended testis; because of the impossibility of ruling out coincident hernia, operative interference is always immediately indicated in these patients. Orchidopexy should be performed immediately when successful detorsion has been accomplished surgically and it is deemed advisable to save the testis. The usual transposition can be done on undescended testes with satisfactory results. In fully-descended testes, any operation that accomplishes shortening of the gubernaculum, with fixation, will achieve success. Simple eversion and suture of the tunica vaginalis is usually sufficient. Orchidectomy. In an adult, when transposition of the undescended testis cannot be satisfactorily accomplished, or in any case in which necrosis, gangrene or persistent circulatory obstruction is present, removal of the testicle and the involved portion of the cord is indicated. Successful surgical detorsion and orchidopexy in acute torsion must be performed in the first few hours after the onset of pain and swelling, or the circulatory damage will be so great that orchidectomy will be necessary. In many patients, because of the frequency of bilateral abnormality, it is imperative to carry out a prophylactic orchidopexy on the opposite side. If there is any question as to the diagnosis, one should err on the side of safety, explore the mass in question and not chance the loss of a testicle. The condition is important enough even to justify exploration
Vincent J. O'Conor
1736
of an acute epididymitis, if this has not been ruled out. Operation, of course, is necessary in all patients in whom strangulated hernia has been mistaken for torsion. If the diagnosis has been missed for several days, and the pain is diminishing without persistent fever, nausea or vomiting, conservative treatment of bed rest, scrotal elevation and hot or cold applications will be the treatment of choice. The end result will be an aseptic necrosis with complete disappearance of the body of the testis. TORSION OF THE APPENDIX TESTIS
The appendix testis, sometimes referred to as the hydatid of Morgagni, is a small, pedunculated, ovoid structure attached to the tunica albuginea propria in juxtaposition to the globus major of the epididymis. Torsion of this structure is of infrequent occurrence and is most frequently seen in prepubertal boys, although ,ve have correctly diagnosed the condition several times in young adults. The symptoms are somewhat similar to those seen in torsion of the spermatic cord, but the pain is usually less severe and there are rarely any constitutional symptoms such as fever or nausea. As in torsion, a secondary hydrocele may develop rather quickly and may interfere with the palpatory findings necessary for an accurate diagnosis. When a small pea-sized mass is palpated distinct from the testis near the upper pole, accompanied by local tenderness, and slight overlying redness and edema of the scrotum occur, the diagnosis should be evident. Spermatocele is the most common condition to be confused on palpation. It is a chronic condition, is rarely tender and is without circulatory effect upon the scrotal skin. Recurrent epididymitis is also an easily confused condition. Treatment consists of surgical excision of the small, pedunculated, edematous and sometimes gangrenous mass. Eversion and suture of the tunica vaginalis should also be done to prevent subsequent hydrocele formation. 720 N. Michigan Boulevard Chicago 11, Illinois