The effect of testicular torsion on fertility

Testicular torsion is a serious medical condition that can cause severe pain, and if not treated quickly, it can lead to permanent damage to the testicle. It most commonly occurs in young people, particularly during adolescence or the beginning of puberty. Torsion can happen on its own without any clear reason or due to trauma, and it can affect one or both testicles. In this article by Deli Medical, we will discuss the causes of testicular torsion, its symptoms, and why it's essential to see a doctor immediately if it occurs.

 

 

1. What are the causes of testicular torsion?
   Testicular torsion occurs when the spermatic cord twists on itself, which blocks the blood flow to the testicle. It is often caused by a strong blow to the area or congenital factors that make the testicle move more freely than usual.

2. What are the symptoms of testicular torsion?
   Symptoms include sudden and severe pain in the testicle, swelling, nausea, and abdominal pain. You may also notice that the testicle is higher than usual or has an abnormal shape.

3. How is testicular torsion diagnosed?
   Diagnosis is based on a physical examination and the use of a Doppler ultrasound to check blood flow to the testicle. In some cases, the doctor may need to perform a surgical exploration to confirm the diagnosis.

4. Can an infant get testicular torsion?
   Yes, but it's very rare, and the exact cause is not well understood.

5. What are the treatment options for testicular torsion?
   The treatment is emergency surgery to untwist the spermatic cord, and if there’s a risk of torsion happening again, the doctor may secure the testicle to prevent future issues.

6. What are the complications of testicular torsion if left untreated?
   If not treated in time, it can lead to testicular loss, affect fertility, and cause permanent reproductive health problems.

How can testicular torsion affect erectile function?

1. Testicular damage
   If testicular torsion persists without treatment, blood flow to the testicle is blocked, which can lead to its death or the need for removal. Although the other testicle might compensate, in some cases, this affects testosterone production, which is the primary hormone involved in sexual function and erection.

2. Hormonal imbalance
   The testicles are the primary source of testosterone production. If there is severe damage to one or if it is removed, testosterone levels may drop, leading to reduced libido or erectile dysfunction.

3. Psychological impact
   The severe pain and stress associated with testicular torsion can cause significant psychological anxiety, which can itself affect erectile function even after recovery. Worry and fear about the recurrence of the problem or loss of sexual function can have a negative effect.

4. Nerve and blood vessel issues
   In some cases, if the damage is extensive, it can affect the nerves or blood vessels responsible for erection, but this is rare.

What should I do if I experience testicular torsion?
Testicular torsion is a medical emergency, meaning you must go to the hospital immediately. Treatment within the first 6 hours preserves the testicle in over 90% of cases, but if the delay exceeds 12 hours, the chances of saving it are significantly reduced. Every minute counts, so if you experience symptoms of torsion, you must see a doctor immediately without delay.

Stages of testicular torsion

Testicular torsion goes through different stages depending on the time passed since it occurred and how much it has affected blood flow to the testicle. The longer the delay in treatment, the more damage occurs, and unfortunately, the testicle may die and require removal.

Stage 1: Partial torsion – (0-3 hours)
What happens?
The testicle starts to partially twist around the spermatic cord, which reduces blood flow, but it still receives some blood.

Symptoms:

• Sudden pain, but not very intense.
• A feeling of discomfort in the testicle.
• The testicle may be slightly higher than usual.

Chance of saving the testicle:
✔ 100% if treated quickly, either by manually untwisting or surgery.

Stage 2: Complete torsion – (3-6 hours)
What happens?
The testicle fully twists around the spermatic cord, greatly reducing blood flow, but there’s still a chance to save it if treated quickly.

Symptoms:

• Severe and sudden pain.
• The testicle has moved higher than normal.
• Redness or slight swelling of the scrotum.
• Nausea or vomiting.

Chance of saving the testicle:
✔ 90% if surgery is performed immediately.

Stage 3: Severe reduction in blood flow – (6-12 hours)
What happens?
Blood flow is almost stopped, and the testicular tissue starts to be affected by oxygen deprivation.

Symptoms:

• Severe, continuous pain that may lessen over time due to nerve death.
• The testicle starts turning blue or dark.
• Severe swelling in the scrotum.
• Fever.

Chance of saving the testicle:
✔ 50% if surgery is performed immediately.

Stage 4: Tissue death – (12-24 hours)
What happens?
Oxygen deprivation leads to complete tissue death in the testicle, and it turns black.

Symptoms:

• Pain may start to subside due to nerve death.
• The scrotum is very swollen, dark red or purplish in color.
• The testicle becomes very firm due to tissue damage.

Chance of saving the testicle:
Less than 10%, and it is usually removed.

Stage 5: Loss of the testicle – (more than 24 hours)
What happens?
The testicle dies completely and loses all function. If not removed, it may cause inflammation or infection.

Treatment:

• Surgical removal of the damaged testicle.
• Fixation of the other testicle to prevent future torsion.
• The patient may opt for a prosthetic testicle if they want a natural cosmetic appearance.

Effect on fertility:

If the other testicle is healthy, fertility should not be significantly affected.
However, if there is a problem with the other testicle, the impact on fertility could be greater.

Causes of testicular torsion:

1. Congenital defect (loosely fixed testicle)
   In some men, the testicle is not properly anchored inside the scrotum due to a condition called "bell clapper deformity." In this case, the testicle is more mobile than normal, which makes it easier to twist around the spermatic cord. This is one of the most common causes and is often hereditary.

2. Sudden movement or intense physical exertion
   Any sudden movement, such as running, jumping, or even tossing in your sleep, can cause the testicle to twist around itself, especially if it's not securely fixed. Intense physical activity or strong movements in the area can increase the risk of torsion.

3. Cold weather
   Extreme cold can cause the muscles supporting the testicle to contract suddenly, which can cause the testicle to shift and twist around the spermatic cord. Some cases occur during sleep in cold environments due to the sudden muscle contraction.

4. Injury or trauma to the testicle
   Any strong blow to the testicle or surrounding area can cause the testicle to move from its place, which may lead to torsion. Even a mild blow can trigger torsion if there’s a congenital predisposition to it.

5. Adolescence and hormonal changes
   Testicular torsion is more common during adolescence (between 12 and 18 years old) because the testicles grow rapidly during this period due to hormonal changes. This rapid growth can affect the way the testicle is anchored in the scrotum, making it more susceptible to torsion.

6. Family history of testicular torsion
   If someone in your family (such as your father or brother) has had this problem, it means you might be more prone to it. The congenital defects that cause weak fixation of the testicle can be hereditary.

7. Undescended or incompletely descended testicle
   Some babies are born with a testicle that hasn't fully descended into the scrotum (cryptorchidism). This can cause problems with its fixation later on and increase the risk of torsion.

Diagnosis of Testicular Torsion

Diagnosing testicular torsion must be quick because time is a crucial factor. If there is a delay, the testicle could be permanently damaged. The doctor begins with an initial examination and may use imaging tests to confirm the diagnosis. Here’s a detailed breakdown of the steps:

1. Physical Examination (The First Step the Doctor Takes)

The first thing the doctor does is examine the testicle by hand to identify signs of testicular torsion, including:

• Severe pain upon touch – Even a light touch causes intense pain.
• Abnormal testicle position – The affected testicle is raised higher than the other or positioned at an unusual angle.
• Swelling and redness in the scrotum – Due to reduced blood flow.

 Prehn’s Sign Test

• If lifting the testicle does not relieve the pain, it strongly suggests testicular torsion.
• If lifting the testicle reduces the pain, the issue may be epididymitis (inflammation) rather than torsion.

2. Ultrasound Doppler Imaging (The Most Important Test to Confirm the Diagnosis)

• This is the key test to confirm the condition.
• A Doppler ultrasound measures blood flow to the testicle.
• In cases of testicular torsion, the scan shows little to no blood flow to the affected testicle.
• If blood flow is normal, the pain might be due to another condition, such as epididymitis.

3. Blood and Urine Tests (To Differentiate Between Torsion and Infections)

• Blood tests can reveal signs of infection, such as an increased white blood cell count.
• A urine test helps detect urinary tract infections or bacterial infections.

4. Exploratory Surgery (If Diagnosis is Unclear)

• If the doctor is unsure of the diagnosis and the Doppler ultrasound is inconclusive, they may perform an exploratory surgery to examine the testicle directly.
• If torsion is found, the surgeon will untwist and secure the testicle immediately to prevent permanent damage.

 Quick Diagnosis is Crucial!

• If testicular torsion is suspected, urgent medical intervention is required, even if imaging results are unclear.
• Delaying treatment beyond 6 hours can lead to permanent testicle damage.
• Surgery is the only solution in most cases, and quick intervention can save the testicle.

Conditions That Can Mimic Testicular Torsion

Several conditions can cause testicular pain and may resemble testicular torsion, but each has distinct differences. Here’s a detailed comparison to help differentiate them:

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1. Epididymitis (Inflammation of the Epididymis)

 What is it?
Epididymitis is an inflammation of the epididymis, the tube that carries sperm from the testicle. It is usually caused by a bacterial infection or sexually transmitted infections (STIs) like chlamydia and gonorrhea.

 How to differentiate it from testicular torsion?
✔ Pain develops gradually, unlike the sudden onset in testicular torsion.
✔ The testicle remains in its normal position (not elevated or twisted).
✔ Pain relieves when the testicle is lifted (Prehn’s sign is positive).
✔ May be accompanied by fever or penile discharge.
✔ Doppler ultrasound shows normal or increased blood flow, not reduced as in torsion.

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2. Orchitis (Testicular Inflammation)

What is it?
Orchitis is the inflammation of the testicle, often caused by viral infections such as mumps. It may also develop if an epididymal infection spreads to the testicle.

 How to differentiate it from testicular torsion?
✔ Pain worsens gradually, rather than appearing suddenly.
✔ The testicle becomes swollen and tender, but not hard or firm.
✔ If caused by mumps, there may be swelling in the salivary glands along with testicular pain.
✔ Blood tests can confirm a viral infection.

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3. Varicocele (Swollen Veins in the Scrotum)

 What is it?
A varicocele occurs when the veins in the scrotum enlarge, causing poor blood drainage. It is more common in the left testicle.

 How to differentiate it from testicular torsion?
✔ Pain is dull and mild, not sudden or severe.
✔ The testicle feels like a bag of worms when touched.
✔ Pain worsens after prolonged standing or physical exertion but improves when lying down.
✔ No sudden swelling, redness, or testicle elevation.

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4. Kidney Stones

What are they?
Kidney stones are mineral deposits that form in the kidneys and can cause severe pain when they move into the ureter (the tube leading to the bladder). The pain may radiate to the testicle.

 How to differentiate them from testicular torsion?
✔ Pain starts in the lower back or side first, then spreads to the testicle (not the other way around).
✔ No swelling or changes in testicle position.
✔ May be associated with blood in the urine or burning sensation during urination.
✔ A CT scan clearly shows the presence of kidney stones.

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5. Inguinal Hernia

 What is it?
An inguinal hernia occurs when a part of the intestine pushes through a weak spot in the abdominal wall, appearing as a bulge in the groin or scrotum.

 How to differentiate it from testicular torsion?
✔ The swelling appears in the groin or scrotum, not directly in the testicle.
✔ Pain worsens with coughing, sneezing, or physical exertion.
✔ You may feel a soft mass that disappears when lying down.
✔ Ultrasound imaging confirms the diagnosis.

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6. Testicular Trauma or Injury

 What is it?
A direct blow or injury to the testicle from a fall, accident, or impact.

 How to differentiate it from testicular torsion?
✔ Pain occurs immediately after the injury and may gradually improve over time.
✔ There may be bruising or discoloration on the scrotum.
✔ Doppler ultrasound shows normal blood flow to the testicle.
✔ No abnormal testicle position or elevation.

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 Quick Medical Attention is Essential!

If you experience sudden and severe testicular pain, seek medical help immediately, as testicular torsion requires emergency surgery to prevent permanent damage.

Types of Testicular Torsion

Testicular torsion occurs when the spermatic cord (which supplies blood to the testicle) twists around itself, cutting off blood flow and causing severe pain. There are two main types of testicular torsion, classified based on age and the mechanism of twisting.

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1. Intravaginal Testicular Torsion – The Most Common Type

 What happens?

• The testicle twists inside the tunica vaginalis, the protective membrane covering the testicle.
• This occurs due to weak ligaments that fail to keep the testicle in place, allowing it to move freely within the scrotum.

 Who is at risk?

• Most common in teenagers and young adults, typically between 12 and 25 years old.
• It can happen after intense physical activity, but it often occurs during sleep without any obvious cause.

 Symptoms:
✔ Sudden, severe pain in the testicle.
✔ Swelling and redness in the scrotum.
✔ Nausea and vomiting.
✔ The affected testicle moves upward and changes position.

 Treatment:

• Emergency surgery is required within 6 hours to save the testicle.
• In some cases, if detected early, a doctor may attempt to manually untwist the testicle before surgery.

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2. Extravaginal Testicular Torsion – Rare and Occurs in Infants

 What happens?

• The entire testicle and spermatic cord twist outside the tunica vaginalis.
• This occurs because the testicular ligaments are not fully developed in newborns.

 Who is at risk?

• Occurs mainly in newborns, sometimes even before birth.
• The exact cause is unknown but is likely related to incomplete fixation of the testicle in its natural position.

 Symptoms:
✔ The scrotum appears swollen and firm.
✔ The skin may turn dark or bluish due to lack of blood flow.
✔ The baby does not express pain, but the affected testicle is visibly swollen.

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 Quick Action is Critical!

If testicular torsion is suspected, immediate medical intervention is necessary to prevent permanent damage to the testicle.

Can Testicular Torsion Be Treated with Medication?

No, testicular torsion cannot be treated with medication alone. The main problem is the twisting of the spermatic cord, which blocks blood flow to the testicle. This requires urgent intervention, either manual detorsion or surgery to save the testicle. However, some medications may help relieve symptoms and reduce complications after surgery.

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1. Pain Relievers and Anti-Inflammatory Drugs

 Purpose: To reduce pain and swelling after surgery.

✔ Paracetamol (Acetaminophen) – Mild pain reliever.
✔ Ibuprofen or Diclofenac – Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) to reduce pain and inflammation.

 Dosage: Taken every 6-8 hours, as prescribed by the doctor.

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2. Antibiotics (Only in Certain Cases)

 Purpose: To prevent or treat infections after surgery, especially if there is inflammation in the scrotum.

✔ Augmentin (Amoxicillin-Clavulanate) or Cephalexin – Broad-spectrum antibiotics.
✔ Ciprofloxacin – Used in specific cases.

 Duration: Usually taken for 5-7 days post-surgery if there is a risk of infection.

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3. Medications to Improve Blood Circulation (Rarely Used)

 Purpose: To enhance blood flow to the testicle after manual detorsion (but not a substitute for surgery).

✔ Pentoxifylline – May be prescribed in some cases to improve blood circulation.
✔ Low-dose Aspirin (75 mg) – Sometimes used to improve blood flow.

 Use with caution and only under medical supervision, as these are not primary treatments for testicular torsion.

Testicular Torsion Surgery

Testicular torsion surgery is an emergency procedure to save the testicle and restore blood flow. The sooner the surgery is performed, the higher the chances of saving the testicle and preventing its loss. The procedure follows specific steps, which I’ll explain in detail.

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1. Preparing for Surgery

✔ Once testicular torsion is diagnosed, immediate surgery is required because time is critical.
✔ The patient receives painkillers and intravenous fluids.
✔ In rare cases, if the diagnosis is unclear, the doctor may attempt manual detorsion, but this is not always effective.
✔ The surgery is performed under general anesthesia so the patient does not feel any pain.

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2. Surgical Procedure

The surgeon follows these steps during the operation:

 Step 1: Making an Incision in the Scrotum

• A small incision is made in the scrotum to access the twisted testicle.
• The affected testicle is usually swollen and discolored due to lack of blood flow.

 Step 2: Untwisting the Testicle

• The surgeon carefully rotates the testicle in the opposite direction of the torsion to restore blood flow.
• After detorsion, the doctor checks if the testicle returns to its normal color, indicating restored circulation.

 Step 3: Fixing the Testicle (Orchiopexy)

• Even after detorsion, the testicle can twist again in the future.
• To prevent this, the surgeon secures the testicle inside the scrotum using permanent sutures.
• In most cases, both testicles are fixed, even if only one was affected, to prevent future torsion.

 Step 4: Checking Testicular Viability

• If the testicle returns to normal, the surgeon closes the incision, and the surgery is successful.
• If the testicle is dead due to delayed treatment (usually after 12-24 hours of torsion), the surgeon removes it to prevent infection.

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3. Post-Surgery Recovery

✔ Going Home:

• The patient is usually discharged the same day or the next day if everything is stable.
• If the testicle is removed, a longer hospital stay may be required for monitoring.

✔ Recovery Period:

• 1-2 weeks of rest, avoiding strenuous activities.
• No heavy lifting or sports for 4-6 weeks.
• Cold compresses help reduce swelling after surgery.

✔ Sexual Function & Fertility:

• If the other testicle is healthy, fertility and erections remain normal.
• If the affected testicle is removed, a testicular implant can be placed for cosmetic reasons.
• Fertility may be affected if the remaining testicle has issues.

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When Is Surgery Too Late?

 If more than 12-24 hours have passed since symptoms started, the testicle is likely permanently damaged.
 If the testicle turns black or loses all sensation, removal is necessary.

✔ Chances of Saving the Testicle:

• Within 6 hours: 90% success rate
• Within 12 hours: 50% success rate
• After 24 hours: Less than 10% success rate

Can Testicular Torsion Be Treated Without Surgery?

In general, testicular torsion cannot be treated without surgery, because the main problem is the twisting of the spermatic cord, which blocks blood flow. The only effective solution is to untwist the testicle and restore circulation as quickly as possible.

However, in rare cases, manual detorsion may be attempted as a temporary measure, but urgent medical follow-up is essential.

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1. Manual Detorsion – A Temporary, Not a Permanent, Solution

 When Can Manual Detorsion Be Attempted?
✔ If the hospital is far away and immediate surgery is not available.
✔ If the doctor believes the testicle is still receiving partial blood flow.
✔ If the patient arrives within the first 6 hours of symptom onset.

 How Is Manual Detorsion Done?
The doctor holds the affected testicle and tries to rotate it in the opposite direction of the torsion:

➡ Right testicle: Usually rotated counterclockwise.
➡ Left testicle: Usually rotated clockwise.

✔ If successful, the pain decreases immediately, and the testicle returns to its normal position.
 However, surgery is still required later to fix the testicle in place and prevent future torsion.

 Risks of Manual Detorsion
 If the testicle is rotated in the wrong direction, the torsion may worsen.
 Manual detorsion is not always effective and may fail to fully restore blood flow.
 The risk of recurrent torsion is very high if surgical fixation is not performed.

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2. Supportive Care After Manual Detorsion

✔ Complete Rest – Avoid any sudden movements or physical activity for two weeks.
✔ Cold Compresses – To reduce swelling and pain.
✔ Painkillers (Paracetamol or Ibuprofen) – To relieve discomfort.
✔ Elevating the Scrotum While Sleeping – Helps improve blood circulation.
✔ Wearing a Scrotal Support – To stabilize the testicle and reduce the risk of re-torsion.

Why Is Surgery Necessary Even After Manual Detorsion?

✔ Without surgical fixation, testicular torsion can happen again at any time.
✔ In 80-90% of cases, torsion recurs within weeks or months if surgery is not performed.
✔ The surgery is quick and simple and prevents torsion from happening again permanently.

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Are There Any Exercises to Treat Testicular Torsion?

There are no exercises to treat testicular torsion because the main problem is the twisting of the spermatic cord, cutting off blood flow to the testicle. The only effective solution is surgery or manual detorsion under medical supervision.

However, after treatment (whether surgery or manual detorsion), some exercises and tips can help with recovery and reduce the risk of recurrence.

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1. Exercises to Reduce Swelling and Improve Blood Flow After Treatment

 Scrotal Elevation Exercise
How to do it:
✔ Lie on your back and place a small pillow under the scrotum to keep it elevated.
✔ Hold this position for 10-15 minutes, repeating 3-4 times daily.

Benefit: Helps reduce swelling and improve blood circulation to the testicle.

Deep Breathing & Relaxation
How to do it:
✔ Sit in a comfortable place and inhale deeply through your nose for 4 seconds.
✔ Hold your breath for 4 seconds, then exhale slowly through your mouth for 6 seconds.
✔ Repeat 5-10 times daily.

Benefit: Helps relax pelvic muscles and improve blood flow.

 Light Walking
How to do it:
✔ Start with slow walking for 10-15 minutes daily, beginning one week after surgery.
✔ Gradually increase the duration if there is no pain.

Benefit: Helps stimulate blood circulation and reduce swelling.

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2. Exercises to Strengthen Pelvic Muscles After Full Recovery

Once the testicle has fully healed, you can do some pelvic exercises to strengthen the muscles and improve blood flow. Always consult your doctor before starting any exercises after surgery.

 Kegel Exercise
How to do it:
✔ Tighten your pelvic floor muscles (as if you are stopping urination) and hold for 5 seconds.
✔ Relax for 5 seconds, then repeat 10-15 times.
✔ Do 3 sets per day.

Benefit: Strengthens pelvic muscles and improves blood circulation to the testicles.

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Which Doctor Treats Testicular Torsion?

The specialist who treats testicular torsion is usually a urologist or general surgeon. Since testicular torsion requires surgery, the condition is managed by a surgical specialist.

 Urologist – A doctor specialized in urinary and reproductive system disorders, including diseases affecting the kidneys, bladder, testicles, and associated structures.

✔ If you are seeking treatment for testicular torsion, it is best to consult a urologist, as they have the expertise to perform the necessary surgery to resolve the problem.