Our patient, which I will tell you about in the Pediatric Surgeon’s Journal, is a 13-year-old male.  He woke up in the morning with a very serious pain in his left scrotum, that is, in his left testicle.  Afterwards, he started to feel sick, and when it got worse, they came to us.  In our examination we saw that the left side of the testis was swollen, was higher than the right side, the size of the testis increased by touch, and the sensitivity of the testicle was noticed. The testis rotated around itself. In this case, which we call testicular torsion, we need to operate immediately. Since the conditions of our hospital were very suitable, we quickly supported our diagnosis with the ultrasonography that we had done while we were going down to the operating room.  Yes, the testicle had rotated around itself.  We detorsioned it, and waited a while.  We took a deep “oh” when the darkened color started to turn pinker because of the return of the blood circulation.  Yes, we saved the testicle.  Because they came early.  Consider your children’s testicular pain.  In a study, testicular torsion was found in 16% of sudden onset testicle pain.  Surgery is the only way to save.  Our topic in the Pediatric Surgeon’s Journal is testicular torsion.  
The patient I told you about a moment ago is not fictional. 
Testicular torsion is more common in adolescents and newborns.  I plan to describe newborns under a separate heading.
Normally, the testicle remains fixed in its bag from the back and thus cannot rotate around itself.  However, in 17% of men, this fixation does not occur and the scrotum can swing in space like a bell.  In fact, this disorder is called  “bell clapper disorder”.  Since it can be 40% bilateral, if there is testicular torsion on one side, we also operate and fix the other intact side.
It is usually seen in men under the age of 30, most often between the ages of 13-14.  Because at this age, the testicles begin to grow rapidly, and when the cremaster muscle, which is the extension of our abdominal muscles and wraps the ligaments of the testicles, is very active, it becomes an invitation to testicular torsion.  Although sports activity is considered among the triggering causes of trauma, it can also occur spontaneously without anything.  Of course, it can also be seen in older men, but the underlying cause at older ages is often a tumor, that is, the presence of a mass.
It mostly affects the left testis, as in our patient, and it can be bilateral in 2%.  About 10% of children with testicular torsion also have a family history of testicular torsion.
Testicular torsion is an important diagnosis for us pediatric surgeons.  If it is delayed, the testis may die because there will be no blood supply to the testis.  In this case, we may have to surgically remove the testis.
Pain begins suddenly in one of the balls, and swelling occurs on that side afterwards.  If it is delayed, the pain will decrease as the testicle dies.  According to our books, one third of patients are accompanied by nausea and vomiting. I’ve never seen testicular torsion without nausea.  When the inner surface of the leg is touched, the cremaster muscle is stimulated and when it contracts, it pulls the testis upwards.  This reflex, which we call the cremaster reflex, is not seen in testicular torsion.  Because the testis has already rotated around its own cord, the length of the cord has shortened, and in this case, the testis has started to stand laterally instead of vertically and higher than normal. If a history of sports activity or a blow is also given, the way to the operating room is now seen.  Sometimes families say they have had similar findings before.  It makes us think that the testis turned around on its own before and then recovered spontaneously, and again supports our diagnosis.
In fact, all of these are sufficient findings for us to perform surgery.  We can use some scoring tables.  Of course, we have weapons that we can get support such as ultrasonography in cases where we are in between.  Surgery immediately if we are sure of the diagnosis.  But if we are not sure, the sensitivity and specificity of color doppler ultrasonography is almost 100%.  There are other methods such as scintigraphy, but we do not use it much in our routine clinical practice.  I read in a study that a quick evaluation can be made with the help of pulse oximetry devices.  I think it makes a lot of sense, but frankly, it’s not needed at all.
It is also reported that testicular torsion can be corrected externally without surgery.  But it is so painful that the children absolutely do not allow us to touch it.  We have a hard time even inspecting.  In addition, the manual external correction method only saves time, the surgery is still performed.
Surgery is needed as soon as possible.  After the first six hours, the testis begins to die.  It is reported that 80% of the testicles die in a waiting period of 36 hours.  In the surgery, as I just explained, we retorsion and fix the rotated testis by making an incision in the middle of the ball and sewing it into the scrotum, and then we also fix the other side, as we know that the same situation can develop on the other side.  Of course, if it’s too late, if we come across a black, that is, dead testicle, we have to take the testicle.  In a recent study, it was published that the testicles had to be removed in almost one-third of testicular torsion operations in children.
Although our results are generally good after the surgery, shrinkage, abscess, and infection can be seen in the testicles, which we think we have saved, over time.  Productivity rates can drop for a variety of reasons.  In the future, we may need to place a testicular prosthesis for aesthetic reasons in children whose testicles we have had to take.
 It’s best to take testicular pain in children seriously. 
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And stay happy.
Prof. Dr. Egemen Eroğlu
October 2021