Testicular torsion: symptoms, treatment. Torsion of testicles in children
in 20% of cases detected during the first 10 years of life. The frequency of diagnosis on average - 1 in 500. Next, we shall understand what is the testicular torsion in men.
Torsion of the testicular cord is a pathological twisting. It provokes the pinching or necrosis of tissues. The torsion of the epididymis is caused by the rotation of the fold between it and the testicle itself. The main role in the etiopathogenesis belongs to mechanical factors.
There are two forms of pathology: extravaginal testicular torsion (in children under one year old, it is detected above the attachment of a leaf from the vaginal process in the peritoneum) and intravaginal twisting. The second form is detected after three years, and most often from 10 to 16. Intravaginal torsion of the testicle (intravaginal form) appears due to the contraction of the muscle that raises the testicle.When this occurs, the elements are raised up. The testicle makes a rotational movement while moving. However, it stops at a certain point. The stoppage is due to the density and rigidity of the adhesions of the membranes, which, together with the inguinal canal covering the spermatic cord in the form of a tube (in older patients), impede the rotation of the testicle around its axis. As a result, the rotation stops. Extravaginal testicular torsion occurs together with its membranes. Fixation of the testicles while not broken. In this case, the morphological immaturity of both the spermatic cord and the tissues surrounding it is of primary importance for the development of pathology.
Causes of pathology
The provoking factors of the pathological condition include injuries, scrotal bruises, sudden movements causing muscle contraction, lifting the testicle, as well as overstrain of the abdominals. In the absence of normal attachment (this anomaly develops during attachment of the appendage), a violation of mutual fixation is observed. In turn, this leads to the separation of formations in the scrotum.Testicular torsion can occur with developmental defects caused by cryptorchidism (impaired migration into the scrotum).
What happens in pathology?
Torsion of the testicles in boys is the turning of the testicles along the vertical axis. If the twist is greater than 180 degrees, then the blood circulation is disturbed, multiple hemorrhages are noted. At the same time venous thrombosis in the spermatic cord is diagnosed. In the cavity of the testicles, a serum-hemorrhagic transudate appears. Torsion of the testicle is accompanied by swelling of the scrotum. The testicle with a relatively long mesentery and, consequently, having a high degree of mobility within the vaginal process in the peritoneum, continues to rotate by inertia. Subsequently, the musculature relaxes. Raised to the upper part of the scrotum, the testicles are fixed in a horizontal position, due to the fact that it is held by convex elements. With the subsequent reduction of the muscles that raise the testicle, the rotation continues. The longer the mesentery, the greater the force of contraction of the muscle fibers that raise the testicles, and their mass is higher, the more pronounced will turn. In the mechanism of the onset of intravaginal torsion, the imbalance in the growth of the elements of the reproductive apparatus is of considerable importance.The frequency of detection in the prepubertal and pubertal periods of intravaginal turns is due to an increase in the weight of the testicles.
Torsion of the testicle in children is accompanied by acute pain in the testicle. They extend to the groin area. The pain corresponds to the zone in which the anomaly is located. For example, if there is a torsion of the left testicle, then discomfort and pain will be on the same side of the groin. In some cases, vomiting, nausea or collapse may occur. The intensity of the symptoms will depend on the age of the patient and the duration of the presence of the pathology. Torsion of the testicle in a newborn is often diagnosed during the initial physical examination. At the same time there is a painless increase in one half of the scrotum. Often this causes redness or blanching of the skin. Infants restlessly suffer pathology, often abandon the chest and scream. At an older age, children complain of pain in the lower abdomen. In the area of the inguinal ring (outer) and the upper third in the scrotum is found tumor-like formation.When a mechanical impact on it appears pain. The twisted testicle becomes more elevated over time. When you try to tighten it even higher, the pain increases significantly.
The consequences of pathology
To prevent severe complications, issues of timely diagnosis, prevention and adequate treatment of pathologies of the scrotum organs are of great importance. Approximately 40-80% of male patients who have been diagnosed with acute pathology, including testicular torsion, show atrophy in the spermatogenic epithelium. Due to this pathology, infertility develops. If conservative therapy was chosen, then testicular atrophy is likely. Late surgical intervention may result in removal of the appendage.
How to determine testicular torsion? Palpation is usually performed in the upper section of the scrotum. During palpation soreness practically does not occur. In some cases, when torsion of the testicle, the appendage may be located in front of the testicle. Subsequently marked hyperemia and swelling of the scrotum. Torsion is accompanied by a thickening of the cord.In connection with violations in the outflow of lymph develops secondary hydrocele. To exclude infectious lesions conduct a urine analysis. During the examination, Doppler ultrasound is prescribed. In the course of it, the architectonics of the testicle itself and its appendage can be seen.
Testicular torsion: treatment
Manual external detortion is a non-drug method of pathology therapy. With timely use of the disease can save 2-3% of patients. The patient takes a horizontal position on the back. The detorsion is performed in the opposite direction to the inversion. In this case, the specialist must remember that the right testicle is rotated in and out, and the left - counterclockwise. When choosing the direction of unwinding, the midline suture on the scrotum is used as a guide. The tissue egg is grasped and rotated 180 degrees. Together with the turn, the testicle is slightly pulled down. This manipulation is carried out several times. With successful detortion, the pain is significantly reduced or the pain disappears completely. The testicle at the same time assumes a normal position and becomes more mobile.In case of failure of the conservative method, detorsion is stopped after 1-2 minutes. The patient is prescribed in this case surgery.
Testicular torsion: surgery
An urgent surgical intervention is prescribed when edema is detected in the scrotum. In this case, the testicle is hypersensitive to ischemia and can stop functioning quickly enough, since irreversible changes occur after six hours. The specialist selects the form of access to the nidus of pathology depending on the type of bloat and the age of the patient. In infants used inguinal method. This is due to the fact that in these patients the extravaginal form of torsion is most often diagnosed. In older patients, scrotal access is used, since the intravaginal type of pathology prevails.
In any form of pathology, the testicle is exposed to the shell. So it is possible to carry out a wide resection. Next, the specialist determines the form of turning. The egg is husked into the wound. The doctor then performs detortion and assesses the viability of the organ.To improve the microcirculation and determine the safety of the element, it is recommended to inject 10-20 milliliters of a 0.25-0.5% novocaine (procaine) solution with sodium heparin into the spermatic cord region. If there is no improvement in blood circulation after 15 minutes, an orchiectomy is indicated. You can also use heat compresses with a solution of sodium chloride (isotonic). They are put on 20-30 minutes. When blood circulation is restored, the testicle acquires its natural color.
One of the most severe consequences of pathology is testicular necrosis. In this case, its removal is likely. In cases where the determination of the viability of an organ is difficult, the use of transillumination studies directly on the operating table is recommended. If the organ is translucent, then it is viable. If this manifestation is absent, it is recommended to make an incision in the albumin membrane at the lower pole. The appearance of bleeding from the blood vessels during this procedure indicates the viability of the organ. When necrosis, despite attempts to improve vascularization, the egg does not change its color.
Completion of the intervention
The stored testicle is sutured to the scrotum septum by the lower ligament. At the same time 2-3 seams are imposed. Elements of the spermatic cord in the process should not be under tension. A drainage tube is inserted into the wound after that. For 2-3 days, irrigation with antibiotics is constantly carried out (in accordance with the severity of inflammation and destructive changes). When torsion of the testicle against the background of cryptorchidism after detortion, the above-mentioned manipulations are also carried out. The atrophied testicle is removed, and the viable is dropped into the scrotum and fixed.
In the course of further management, the patient is recommended physiotherapy, drugs that normalize the microcirculation, and sensitizers. Novocainic blockade of the spermatic cord is carried out daily, intramuscular injection of heparin sodium and other drugs is carried out. To reduce the permeability of the blood-testing barrier after surgery, the patient is prescribed 0.3–1.5 grams / day of acetylsalicylic acid for six to seven days. If necessary, you can subsequently apply preventive orchippexy (fixation of the testicle to the tissues) on the other hand. This procedure will prevent a turn in the future.As practice shows, while preserving the dead testicle, antispermal bodies begin to appear in the body over time. Often torsion moves to the second testicle. In this case, the risk of infertility increases significantly.
Clinical and morphological studies
Experts have found that similar, often identical processes are characteristic of various forms of acute pathology in the scrotum organs. They manifest in the form of neurodystrophic changes in the tissues and the corresponding clinical picture. As provoking factors, as a rule, are identical changes in spermatogenesis. They are expressed in prospermia, reduction of the area of the head and nucleus of germ cells, disorders in the concentration of trace elements in the composition of the ejaculate. These and other factors cause the recent trend of early surgical intervention in acute pathologies in the scrotum organs. Using the operative method allows you to quickly eliminate ischemia, timely diagnose the disease. This, in turn, increases the chances of preserving the functional ability of the testicles.