Even a slight delay in treatment can result in the loss of a testicle, writes Michael Kelly
VERY OFTEN when we talk about men's health we are talking about long-term health issues - diseases or illnesses which take a considerable length of time to materialise and remedy.
Testicular torsion (where the spermatic cord becomes twisted, cutting off the blood supply to the testis), on the other hand, is a medical emergency that affects young men where even a slight delay in diagnosis and treatment can have devastating results, including the loss of a testicle.
Testicular torsion predominantly occurs in men younger than 30 years of age, with the majority occurring between 12-18 years of age. In adolescent males, testicular torsion is the most frequent cause of testicle loss. Thankfully though, incidences of torsion are relatively rare - affecting about one in 4,000 men.
When it does occur, the key to salvaging the testicle is for treatment (known as detorsion) to be administered within hours, which means that knowing the signs of an impending torsion is one of the key factors in a successful outcome.
For patients who receive treatment within six hours of the onset of pain, there is a testicle salvage rate of 100 per cent. That rate falls to 20 per cent if treatment is not delivered within 12 hours and 0 per cent if delayed greater than 24 hours.
Unfortunately, many young men may be reluctant to seek medical attention for conditions involving their genitals, even when there is acute pain involved. A 2000 study on testicular health awareness found that 85 per cent of respondents did not think it was necessary to seek attention for testicular swelling.
"Torsion has to be viewed as a medical emergency rather than just urgent," says consultant urologist Mr Hubert Gallagher. "I would recommend that any boy or young man who is experiencing acute scrotal pain should go straight to AE rather than their GP. The first six hours after the onset of symptoms is absolutely crucial."
So what is a testicular torsion and what causes it?
A torsion occurs when the testis rotates and the spermatic cord (which carries the blood and nerve supply to and from the testis) becomes twisted, cutting off the blood supply. The most common cause of torsion is the presence of what is called the bell clapper deformity, an anatomic abnormality present in about 12 per cent of males which allows the spermatic cord to twist more easily.
In some cases, the simple act of growing can be a factor - most incidences of torsion occur during puberty when a boy's testes are growing by a factor of five to six. While torsion most commonly occurs spontaneously, various conditions are believed to act as triggers including sexual arousal and activity, trauma to the genital area, physical work or exercise.
A torsion is typically marked by the onset of severe and sudden scrotal pain (patients usually describe it as being "doubled over" in pain). The pain is often accompanied by swelling and discoloration of the scrotum, and because the spermatic cord shortens as it twists, the testis may appear higher on that side. Other symptoms include nausea and vomiting.
While the most common cause of testicular loss during a torsion is a delay in seeking medical attention, incorrect initial diagnosis by medical professionals also plays a part (in about 30 per cent of cases).
Doctors and urologists face a difficult task in quickly diagnosing testicular torsion since acute scrotal pain could be a sign of other conditions including trauma, epididymitis, hernias, appendicitis, varicocoele or scrotal oedema.
"It can be easily mis-diagnosed," says Gallagher. "For example, sometimes the pain from torsion is referred to the upper abdomen and the patient may not be sure that the pain is in the testicle itself.
"Or you could have a boy who gets a bang on the groin in school and a few hours later he starts to get acute pain - he is putting that down to the bang when in fact it could be the start of a torsion."
The starting point for doctors, he says, will be to get a detailed history and to physically examine the patient.
"I often think if the patient will allow me to physically examine the area, then it's less likely to be a torsion. It's not a black and white rule but usually the area is so sensitive they won't let you near it."
At that point, doctors are facing a decision on whether to surgically explore to continue the diagnosis. An alternative is the use of an ultrasound to determine whether there is still a blood flow to the testicles - but this approach can be problematic, according to Gallagher, and most doctors will typically not risk permanent damage to the testicle by taking the time to perform an ultrasound.
"There can still be some blood flow with a torsion so the ultrasound is not always 100 per cent accurate. The golden rule for urologists in this dilemma is that you should always, always examine if you are in any doubt. A lot of the time when you make the decision to explore surgically, there could be nothing there but you have still done the right thing."
If a torsion is confirmed during the surgical procedure, the surgeon will untwist the spermatic cord and restore the blood supply to the testis.
Having done this, surgeons will typically stitch the inside of the scrotum on both testicles to prevent torsion occurring in the future (this procedure is called an orchiopexy).
If a torsion is treated promptly, the testis will recover completely. However, if the blood supply has been cut off for a long time and the testis is not viable, it is removed. The loss of a testicle can be a devastating outcome for a young man physically and emotionally, although it does not necessarily result in impaired fertility. "If the other testicle is in good condition, there is no reason why fertility should be impacted," says Gallagher.
"But even so, the loss of a testicle has a huge psychological impact, particularly for young men who may not be in a long-term relationship."
Some men opt for the insertion of a prosthetic testicle and studies have found that this leads to an improvement in self-esteem. "A prosthesis is used purely for aesthetic or psychological reasons but they are very effective. They look and feel very realistic."