Injuries Of Testis And Testicular Torsion

A testicular injury might manifest in two different ways.
It could be a minor testicular injury or a large intratesticular hematoma.There are two possible presentations of a large intratesticular hematoma.

In the event that either the tunica vaginalis or the tunica albuginea are compromised. The patient will present with a hematocele to the physician if there is a breach in the tunica albuginea and the tunica vaginalis is present. The main distinction between it and a hydrocele will be the presence of blood within the tunica vaginalis.

However, since the blood is free to enter the scrotum in this specific case, presuming that the tunica vaginalis is also somewhat of a breach, the patient will present to the physician with a scrotal hematoma. As a result, the perineum and groin will get blood. In the event that the patient's vaginalis ruptures in the second scenario, they will have hematocele if the patient's tunica albuginea is the only affected area.

When a patient is suspected of having a testicular rupture, the preferred course of inquiry is an ultrasound.  In addition, they must carry out the surgical exploration, fix that specific layer, and achieve hemostasis if there is a testicular rupture or a fast growing dislocal hematoma in this case.

Testicular Torsion

A disorder known as testicular torsion causes the testis to twist around its own axis.Since the gubernaculum typically inserts the testis into the scrotum, it does not ordinarily occur.However, the testicles will revolve on their own axis if they are not fixed.
The testis will become necrotic as a result of the cessation of venous and arterial blood flow.

Predisposing Factors

• High investment of Tunica Vaginalis 
• Inversional of testis 
• Separation of epididymis from body of testis 
• Testicular torsion occurs if there is
  • High investment in tunica vaginalis.
  • Inversion of the testis
  • Separation of the epididymis from the body of the testis

High Investment of Tunica Vaginalis

The testis's outermost layer is the tunica vaginalis. Investing more causes the testes to bend sideways, a condition known as bell-clapper deformity. This is the most prevalent predisposing factor.  It typically results in bilateral abnormalities and is the most frequent cause in adolescence.  Because the patient only suffers unilateral testicular torsion, this deformity is bilateral, meaning it also exists on the other side.

Q.: What is the most common predisposing factor for testicular torsion?

·       Bell-clapper deformity

Separation of Epididymis From the Body of Testis

The epididymis normally rests on top of the testis, but if they are separated, they can rotate on a specific stop, which can cause testicular torsion. It also allows the testis to torsion on the pedicle that connects the testis to the epididymis. In the event that the testis and epididymis are separated, they will be joined to one another by mesentery.

Presenting Feature Of Testicular Torsion

• It occurs at a younger age, around 10 to 25 years old. It will be presented at 40, 50, or 60 years of age.
  • Pain in the abdomen
  • Nausea
  • Vomiting
  • The scrotum is tender and swollen.
  • A tender twisted cord is palpable.
  • The cremasteric reflex is lost.

Differential Diagnosis For Testicular Torsion 

• Torsion of hydatid of morgagni, this is called the appendix of the testis.
• Epididymo Orchitis
• Mumps orchitis
• Idiopathic oedema of scrotum
• These are the differential diagnosis of testicular torsion.

Q. Appendix of testis is a Remnant of ?

·       Mullerian duct.

Also Read: Anatomy Of The Testis And Its Types

Appendix of Testis

 An appendix is a protracted structure that surrounds the cecum if one exists.  Similarly, the appendix of the testis refers to the stock or pedicle that sits above the testis.  The testicular appendix is a piece of the Mullerian duct that remains.  The pedicle on the epididymis is referred to as the appendix of the epididymis, much like the testis.

The paramesonephric duct, also known as the Wolffian duct, is remnanted in the appendix of the epididymis. This structure inverts upon itself, and there is stock.  Even in these cases, the patient will present to the ER complaining of scrotal soreness. The twisting will produce excruciating pain inside the scrotum, and that appendix will lose its blood supply. It will hurt from itching and necrosis.

Blue Dot Sign

Blue dot sign: The skin around that area turns blue due to the stock twisting; if it seems necrotic or blue, the surrounding skin will be normal. ., This is known as the "blue dot sign" that is seen in the hydatid of Morgagni's torsion.Giving NSAIDS and painkillers for a few days can help it settle down as a treatment.

Phren Test

Epididymo orchitis is a crucial differential diagnosis for testicular torsion.  The Phren Sign can be used to distinguish between epididymo orchitis and testicular torsion.  In the sign of Phren, if testicular elevation, which lowers pain and may indicate epididymo orchitis.  Elevation of the testis, which causes a pain spike that may indicate torsion of the testicles.

In the clinical scenario, a male patient, age 21, presents himself to the emergency room complaining of pain in his testicles. The pain intensifies with testicular elevation, and the cremasteric reflexes are closed upon examination. Torsion of the testicles is then the defining characteristic.

In the same case, a male patient, age 21, visits the doctor complaining of pain in his testicles. There are cremasteric responses and less discomfort when elevating the testis which indicates epididymo orchitis.

Doppler  

The primary issue with testicular torsion is the interruption of the testis' blood supply.  In the event of testicular torsion, the blood supply is absent during doppler imaging.  Doppler is not usually advised since it could produce a false positive result.

Epididymo orchitis is an inflammatory disease; increased blood flow is observed to the affected area if there is an infection or inflammation.  There will be more blood flowing to the testis when epididymo orchitis is present.

There will be less blood flowing to the testis when there is testicular torsion on the doppler.  In many instances, ultrasonography quality is extremely low in India, and radiology may not be available in all facilities. In the event that the patient arrives at a small medical facility complaining of testicular pain, a doppler should be performed.

The next step before operating on the patient is scrotal examination if there is no doppler. Thus, the doppler verifies that there is no blood flow.  Because it could have unfavorable effects, it is not advised frequently. It is possible if it is available.

Also Read: High-Yield NEET SS Surgery Urology Questions

Painful Scrotal Swelling 

 Because the outcome of the operation will determine whether or not the testis can be saved, if a patient presents with painful scrotal swelling and the clinical examination is inconclusive in determining whether the patient has a dorsion or epididymo orchitis, the patient will undergo scrotal exploration if the doppler is not available for use.  In the event that there is any room for question, this should be done.

Surgery

 A transverse scrotal incision can be made to facilitate scrotal examination.  If the testicles are viable after delivery, they are attached to the scrotum using three non-absorbable sutures, which are placed between the testicles' tunica albuginea and median raphe. In other words, the testicles are fixed at three sites before being torn again.Orchiectomy is an option if the testicles are not viable.

Doubt of Vascularity

 If vascularity is uncertain, apply a warm swab to the testis and wrap it there. The warmth will essentially improve blood flow, so watch for a few minutes. If the testis seems viable, wrap it in the worm swab, fix it, and it will survive. Nevertheless, if the testis's blood supply is really inadequate, the testis will get infarcted, necessitating an orchiectomy.Proceed with the bilateral orchidopexy if the testicles are viable.

Q. How many testis percentage of testis with testicular torsion can be salvaged if they are untwisted in 24 hours ?

The answer is 20%

Also Read: Urological Trauma And Indications Of Radiological Assessment

Salvation Of The Testis

 There are two factors involved.  The degree of the testis is another factor.  Compared to a 360-degree twist, there is a lower likelihood of salvaging when the twist is 720 degrees.
Thus, greater twisting results in less blood traveling to the testis and less testis salvage.  One hundred percent of the testicles can be preserved if these patients receive surgery within six hours.

Q. What is the golden time for testicular torsion?

The answer is six hours.

However, in that circumstance, only 20% of the patients' testicles can be saved if they undergo a 24-hour operation.Thus, the testis's ability to survive depends on the extent of the twist and the timing of the patellae's action.

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