This review article is worthy of reading in its entirety. It addresses current concepts in the management of one of the few paediatric urological emergencies. For every 100,000 males <25 years, 4.5 will have testicular torsion per year. Given that if pain has been present for more than four to eight hours the rate of testicular salvage is low, rapid diagnosis and appropriate management is of the essence in preventing testicular loss. The ‘bell clapper deformity’ predisposes to intravaginal torsion but it is also found in 12% of autopsies of men who have never had torsion (which is greater than the incidence of torsion). The INSL3 hormone and its receptor RXLF2 have been investigated as candidate genes for a familial inheritance / predisposition as INSL 3 acts on early gubernacular development and masculinisation with enlargement, with lack of this leading to the cryptorchid testes. Mutations in these genes have not however been found to predispose to torsion in mice. ‘To image or not to image’ continues to be contentious. Colour doppler ultrasound (CDS) is the first test to rule out torsion in the acute scrotum but remains operator dependent. It gives a 100% predictive loss at exploration if parenchymal heterogeneity of the testicular echotexture is identified allowing for more accurate preoperative planning and counselling. High resolution ultrasound (HRUS) with a ‘whirlpool sign’ describing the twist of the testicular cord has a sensitivity of 96% and specificity of 99% compared to 76% for both for CDS. Near infrared spectrometry (NIRS) obtains continuous non-invasive transcutaneous monitoring of tissue oxygen saturation. A US National Institutes of Health (NIH) funded trial in children with suspected testicular torsion is underway and this may become the point of care diagnostic test in the future. Exploration is still the gold standard if in doubt and if time is of the essence. What to do during surgery to preserve the testis? There are advocates of tunica albuginea incision and tunica vaginalis patch placement as a form of fasciotomy and relief of compartment syndrome of the testis. Both animal models and a small clinical series of patients seem to corroborate this concept by demonstrating preservation of testicular size and growth on one-year follow-up. Perinatal torsion (prenatal or immediately postnatal) management remains controversial. It can be bilateral in 22% of cases – occurring synchronously in 67% of these and so early exploration is advocated. This has to be weighed up against the anaesthetic risks, the poor salvage rate (although this is better in the postnatal group than the prenatal group). Most paediatric urologists advocate immediate exploration in bilateral cases with fixation of the testis rather than orchidectomy as Leydig cell function is more resistant to ischaemia at this age, preserving some hormonal function. A number of drugs have been studied to identify effects on the ischaemia – reperfusion germ cell damage of torsion and untorsion. Phosphodiesterase type 5 (PDE5) inhibitors, such as Verdenafil and Sildenafil, have been found to be protective against reperfusion injury in rats. Similar results have been shown for poly ADP ribose polymerase (PARP) inhibitors, Ginkgo Biloba, lycopene and Coenzyme Q10. The world of testicular torsion is obviously changing in some ways but in some remains the same.
New concepts, emerging technologies and potential therapeutics in testicular torsion
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