CNA – Persistent pain in men is always concerning, particularly when it involves the testicles. One serious condition to be aware of is testicular torsion.
This term might sound familiar, especially if you’ve come across the recent story about a teenager who lost a testicle due to a misdiagnosis and delayed treatment.
The teenager first visited a doctor for “pain in his left abdomen originating from his left testicle” and “increased bowel movements with watery stools.”
He was incorrectly diagnosed with gastrointestinal problems and given antibiotics to address the pain and inflammation in his scrotum.
Despite several follow-up visits to the same physician, his condition deteriorated.
Ultimately, he required surgery to remove the affected testicle.
WHAT IS TESTICULAR TORSION?
What is testicular torsion, and could you be at risk? Here’s the insight from urologists:
Each testicle is attached to the spermatic cord, which contains blood vessels, nerves, and the vas deferens – a tube that transports sperm from the testicle to the penis.
Testicular torsion happens when a testicle twists inside the scrotum, causing the spermatic cord to twist and cut off the blood supply. This is explained by Dr Edwin Jonathan Aslim, a consultant from the Department of Urology at Singapore General Hospital.
“This can result in infarction (tissue death due to inadequate blood supply) of the affected testis if the arterial blood supply is not restored,” said Dr Lim Yong Wei, a consultant from Department of Urology, Sengkang General Hospital.
The repercussions aren’t pleasant. There’ll be a sudden onset of pain over a few hours, said Dr Lim, and this is pain that is “out of proportion to any injury suffered by the individual”. However, there is usually no sign of fever and urinary problem, he said.
The affected testicle may also be higher than the other one and lie horizontally in the swollen scrotum, according to Dr Chong Weiliang, a consultant with National University Hospital’s Department of Urology. Other symptoms may include nausea and vomiting.
HOW COMMON IS IT AND ARE YOU LIKELY TO DEVELOP THE CONDITION?
Testicular torsion can occur at any age, said Dr Aslim, but is most commonly seen in two age groups: During infancy and between 12 and 18 years old. “In adults, we occasionally see these cases in young men presenting to the emergency department, perhaps fewer than five per year,” said Dr Aslim.
While there hasn’t been any local data on testicular torsion cases, the incidence rate could run between 3.5 and 15 per 100,000 males below the age of 25, said Dr Aslim, citing studies done in Asian countries such as South Korea, Taiwan and Japan.
Dr Lim’s department has attended to close to 20 cases of testicular torsion in the last two years. “Five of these cases required the removal of the affected testis,” he said. According to him, testicular torsion usually affects one testis at a time and it’s often the left testicle, he said, citing a 1998 paper on 670 patients in the UK.
Dr Chong also mentioned that cases are “relatively uncommon” and sees an estimated one or two cases a month. “From historical data, patients with such a predisposition would have mostly presented by the age of 25, though outliers can present later.
“One big factor,” he continued, “which predisposes patients to testicular torsion is the laxity of the attachments between the testis and the surrounding scrotal walls.” This allows the testis to move more than usual.” According to him, laxity can affect both testes.
This laxity is likely owing to Bell-Clapper deformity, “a developmental anomaly affecting the tissue layers enveloping or wrapping the testes”, explained Dr Aslim. As a result, the testes are “not properly anchored in place, making them prone to loosely twist and turn within the scrotum”.
“Bell-Clapper deformity often affects both testicles, with rates as high as 100 per cent in some studies,” said Dr Aslim, adding that the condition tends to run in the family.
DO UNDERWEAR CHOICE AND SPORTS INJURIES INCREASE THE RISK OF TESTICULAR TORSION?
Maybe not underwear choice. “There is currently no evidence in medical literature to recommend a choice of underwear between boxers and briefs,” said Dr Lim. “We are still not clear on the exact mechanism that causes testicular torsion. We understand that it occurs spontaneously.”
But “physical trauma can occasionally be a trigger”, said Dr Aslim. “Therefore, contact sports may, in theory, trigger (testicular torsion) if there is a blow or trauma to the scrotum or testis.”
It doesn’t hurt to get some protection down there when playing football, guys.
CAN YOU MASSAGE THE SCROTUM TO UNTWIST THE TESTICLE?
“Massaging the scrotum is not recommended as it’s unlikely to untwist the spermatic cord and may even worsen the twisting,” said Dr Chong.
Furthermore, the patient will be in too much pain to withstand any form of massage, said Dr Aslim. Massage is also not recommended if it results in delay to seek medical help, he said.
IS SURGERY THE ONLY FORM OF TREATMENT AVAILABLE?
Testicular torsion is an emergency and immediate surgical intervention is required to salvage the affected testicle, said Dr Chong.
During the procedure, the testicle is untwisted to restore blood flow, then stitched in place to prevent it from twisting again. Doctors typically also anchor the other unaffected testicle, he said.
Interestingly, in some cases, the twisting may spontaneously undo itself and end the pain and other symptoms, according to Dr Aslim.
While this may spell good news for the patient, it’s not so much for the doctor as it is challenging to diagnose the condition without “symptoms and/or abnormal findings”.
At times, the testicular torsion may recur and surgery may still be needed.
However, you shouldn’t put up with the pain and wait for the off chance that the testicle may untwist itself. Time is of the essence as the longer the torsion is allowed to manifest, the more damage the testicle accumulates, highlighted Dr Aslim.
For comparison, the success rate of salvaging the testicle is 84 per cent to 100 per cent when operated within six hours from the start of the symptoms, said Dr Lim; this rate drops to 50 per cent if the symptoms started six to 12 hours ago. It drops to a dismal 4 per cent if the patient was operated on 12 to 24 hours later, he said.
“If the torsion has been present for too long and the testicle is unsalvageable, an orchidectomy will be performed,” said Dr Chong, to surgically remove the testicle.
HOW WOULD LOSING A TESTICLE AFFECT FERTILITY?
It wouldn’t, said Dr Chong, if the other testicle is healthy. “However, it can reduce the overall hormonal production and semen quality due to the reduced production of sperms.”
Added Dr Aslim: “In cases where the other testicle is abnormal or lost, then losing a testicle may lead to infertility and problems with male physical development”.
Other issues may include psychological distress from the loss of a sex organ, noted Dr Chong.
“Regular check-ups with a healthcare provider are essential to monitor hormonal levels and the affected testicular size after testicular torsion,” he said.
