Testicular Torsion and Orchitis

• Testicular torsion and orchitis are conditions affecting the male reproductive system

Introduction to Testes

• The testes, also known as testicles, are oval-shaped organs in the male reproductive system
• They are located in the scrotum, a sac of skin that hangs outside the body in the pelvic region near the upper thighs
• The main function is to produce and store sperm
• Testes are crucial for creating testosterone and other male hormones called androgens
• Testosterone is important for male development and maturation, including muscle development, voice deepening, and hair growth

Testicular Torsion

• Occurs when tissues around the testicle are not well-attached, causing the testes to twist around the spermatic cord
• The twisting cuts off blood flow to the testicle
• This results in pain and swelling and requires emergency treatment

Normal Testicular Incidence

• The testicles are two organs housed in the scrotum, which sits below the penis
• The testes produce sperm and testosterone
• Blood supply to the testicles is provided by the spermatic cord, extending from the abdomen into the scrotum
• The spermatic cord contains the vas deferens, which carries sperm from the testicles to the urethra

Incidence of Testicular Torsion

• The total testicular torsion mostly occurs in infancy or adolescence
• The total testicular salvage rate was 75.22% and highest in children at 79.91%
• It affects about 1 in 4000 to 1 in 25,000 males under the age of 25 each year
• It is most common in adolescents between 12 and 18 years old
• It can occur in newborns and older men

Classification of Testicular Torsion

• Intra-vaginal torsion: the most common type of testicular torsion
• It occurs with high fixation of the tunica vaginalis to the spermatic cord (bell clapper deformity)
• Bell clapper deformity allows the testis to hang freely in the scrotum, leading to twisting
• The significant consequence of torsion of the spermatic cord is testicular ischemia
• Extra-vaginal torsion: also known as perinatal testicular torsion; exclusively occurs during this stage of life
• In extra-vaginal torsion, the entire cord including the tunica vaginalis twists because it is not yet fixed within the scrotum
• Results from poor attachment of the testis to the scrotal wall
• This allows rotation of the testis, epididymis, and tunica vaginalis as a unit and causing torsion of the cord at the level of the external ring

Risk Factors for Testicular Torsion

• Modifiable risk factors include trauma, bell clapper deformity, undescended testicle, and prior intermittent torsion
• Non-modifiable risk factors include age (most common 12-25 years), previous testicular torsion, and family history of testicular torsion

Etiology Factors for Testicular Torsion

• Vigorous activity
• Minor injury to the testicles or while sleeping
• Cold temperature
• Rapid growth of the testicle during puberty

Pathophysiology of Testicular Torsion

• The testicle rotates on the spermatic cord
• This leads to venous occlusion and edema
• Arterial ischemia follows
• Resulting in infarction

Clinical Manifestations of Testicular Torsion

• Tenderness, swelling, or redness in the scrotum or testicles
• Nausea and vomiting
• Fever
• Sudden, severe pain in the scrotum
• Frequent urination
• A testicle positioned higher than normal or at an unusual angle

Complications of Testicular Torsion

• Atrophy
• Infertility
• Scrotal abscess
• Hydrocele
• Cosmetic deformity
• Chronic scrotal pain
• Ischemia and infraction of the testis

Diagnostic Studies for Testicular Torsion

• History collection involves gathering information about testicular pain, onset, lower abdominal pain, nausea, and vomiting
• A history of previous testicular pain may suggest intermittent torsion
• Physical examination includes inspecting the testes for enlargement and the scrotal region for tenderness and erythema
• Non-invasive procedures use ultrasound, urine tests, Doppler ultrasound, and infrared scrotal spectroscopy
• Invasive procedures use blood tests

Medical Management of Testicular Torsion

• Analgesics for pain relief
• Antiemetics for nausea and vomiting
• Anti-inflammatory agents
• Anti-anxiety agents

Surgical Management of Testicular Torsion

• Orchiectomy (Orchidectomy): surgical removal of one or both testes after examining inflammation, if no improvement after 2-3 days
• Orchiopexy: corrects testicular torsion and prevents recurrence
• Scrotal exploration surgery: an operation under general anesthesia to untwist the testicle

Pre-operative Procedure for Testicular Torsion Surgery

• A blood sample is taken to check for cancer or fitness for surgery
• The risks of anesthesia should be explained
• Consent should be obtained from the patient's party and surgeon
• The surgery should be scheduled for a specific date

Post-operative Procedure for Testicular Torsion Surgery

• The patient is sent home a few hours after orchitis treatment
• The patient should have a follow-up visit the day after surgery
• Wear a scrotal support for 2 days
• Apply ice to reduce swelling
• Gently wash the area with mild soap
• Keep the incisional area dry and cover with gauze for a few days
• Take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief
• Drink more water and eat high-fiber foods to prevent constipation
• Avoid exercise, sports, and running until fully healed (weeks to months)

New Researches on Testicular Torsion

• Outcomes rely on how quickly the patient presents and diagnosis and treatment occur
• Delays can lead to testicular atrophy
• In 20-40% of cases, orchiectomy results
• The risk of losing a testis is higher in African Americans and younger males
• Nearly 100% salvage rate presenting within 6 hours of symptom onset
• Salvage rate drops to less than 50% if the delay is more than 12-24 hours

Orchitis

• Refers to inflammation of one or both testes
• Orchitis alone is rare, usually occurring with epididymitis

Incidence of Orchitis

• Orchitis develops in 14-35% of males with mumps
• It's commonly seen in outpatient settings, affecting men between 14 and 35 years old
• In 2002, orchitis accounted for 1 in 144 outpatient visits in California hospitals
• In the U.S., approximately 600,000 orchitis cases are reported annually

Classifications of Orchitis Based on Organisms

• Bacterial orchitis: Due to bacterial infection of the epididymis, leading to epididymo-orchitis
• Viral orchitis (mumps orchitis): Due to mumps viruses

Classifications of Orchitis Based on Onset and Duration

• Acute orchitis: Caused by viral infections (e.g., mumps virus), felt quickly within six weeks
• It is fully recovered with or without treatment
• Chronic orchitis: Often due to bacterial infections, progress is slow, causes long term problems (more than six weeks) and improve with treatment

Etiology of Orchitis

• Modifiable etiologic factors
• Bacterial and viral infections: main factors leading to orchitis
• UTIs and STIs are secondary infections
• Staphylococcal and streptococcal infections, prostatitis, and UTIs can lead to orchitis
• Viruses responsible for orchitis include mumps, rubella, chickenpox, CMV, and coxsackie virus
• Inflammation from systemic infections
• Strenuous physical activity
• Bicycle riding and prolonged sitting
• Trauma to the testis and tumor formation

Non-Modifiable Risk Factors of Orchitis

• Gender: Male
• Age: Men between 15 to 35 years are physiologically and sexually active
• Genetic factors: Some believe it's genetically transmitted, but statements are unproven

Pathology of Orchitis

• Orchitis is inflammation of the testicles, occurs with epididymitis and rarely occurs alone
• Usually caused by bacterial infection of the epididymis, connecting the vas deferens and testicles
• The epididymis transfers semen, moving bacteria and viruses to the testicle
• Resulting in inflammation of both epididymis and testicle, called epididymo-orchitis

Flow Chart for Orchitis

• Epididymitis
• Causative agents move from epididymis to testicles
• Direct trauma or secondary to organisms directly entering the scrotum
• Inflammation of testis
• Inflammatory fluid forms and accumulates in the scrotal sac
• Unilateral or bilateral testicular swelling

Clinical Manifestations of Orchitis

• Signs:
  • Swelling in one or both testicles
  • Blood in the semen
  • Swollen lymph nodes in the groin region
  • An enlarged prostate
  • Abnormal discharge
• Symptoms:
  • Painful urination
  • Painful ejaculation
  • General feeling of discomfort and unwell (malaise)
  • Nausea and vomiting
  • Fever
  • Testicle pain ranging from mild to severe depending on the disease's nature
  • Rapid heartbeat (tachycardia)
  • Headache
  • Fatigue
  • Muscle pain

Complications of Orchitis

• Testicular atrophy: Orchitis can shrink the testicle
• Scrotal abscess: Accumulation of pus in infected tissue inside the scrotum
• Infertility: In untreated cases, orchitis can lead to infertility and inadequate testosterone, known as hypogonadism
• Hydrocele: Fluid buildup in the scrotum leads to edema
• Chronic scrotal pain
• Ischemia and infraction of the testis

Diagnostic Studies for Orchitis

• History collection includes asking about past and recent genital infections, injuries to the scrotum genital area, hepatitis/AIDS, and pain while sitting or walking
• Physical examination includes inspecting for scrotum swelling, groin lymph node enlargement, abnormal discharges, and gait, and assessing cremasteric reflex
• Non-invasive:
  • Ultrasound with color Doppler: Assesses blood flow in the testicles
  • Urine test (Urinalysis): Analyzes for abnormal discharges
• Invasive:
  • STI screen: Collects discharge samples for screening organisms, i.e. gonorrhea and chlamydia
  • Blood test: Complete blood count helps rule out infection and inflammation

Management of Orchitis

• Pharmacological Management for Bacterial Orchitis Range of age - Medications and their alternatives
• Men (10-35) - Ceftriaxone and Doxycycline
• Men (>35) - Levofloxacin, Ciprofloxacin, Ampicillin-sulbactam, and Ceftriaxone
• Viral orchitis treatment
  • MMR vaccines for developing immunity before exposure to mumps
  • This is life-long immunity

Surgical Management of Orchitis

• Orchiectomy (Orchidectomy) is the surgical procedure which includes removal of one or both testes after examining the inflammation involvement. It is done only when there is no clinical improvement for first 2 to 3 days after the treatment. Four types of orchiectomy include: - Simple orchiectomy- Commonly performed for advanced cases of prostate cancer as a part of palliative treatment and during testicular torsion. In this case, the whole testis with glandular tissue is removed. - Subcapsular orchiectomy- This procedure is just like a simple orchiectomy, but in this case, the glandular tissue that surrounds the testis is removed rather than the whole testis. It is performed to remove testosterone to regain normal scrotal anatomy. -Inguinal orchiectomy- This procedure is performed when testicular cancer is assumed to prevent the possible spread of cancer from the spermatic cord into the other lymph nodes. In this case, the whole spermatic cord along with testicles are removed from the inguinal canal. -Partial orchiectomy- In this case, the testis is exposed, and the spermatic cord is clamped, but the testis and its function are preserved. The abnormal testicular masses are removed, and some portion is sent to the lab as biopsies.

Pre-operative and Post-operative Procedures

• Pre-operative procedures -A blood sample is taken to examine that the patient is healthy enough to have surgery -We should explain to them the risk of anesthesia -Before the appointment, obtain consent from both the patient's party and the surgeon, who should agree to have the surgery on one particular date Post-operative procedures -The patient is sent home a couple of hours after the orchitis. Recommend the patient to visit the hospital for a checkup day after the surgery.
  • For the first week of surgery -The patient should wear scrotal support for 2 days -The patient should use ice to reduce swelling -Advise the patient's attendant to gently wash the area with mild soap -Advise the patient to keep the incisional area dry and covered with gauze for a few days -Advise the patient to be taking nonsteroidal anti-inflammatory drugs (NSAIDs) for relieving the pain -Advise the patient to drink more water and eat high-fiber foods to keep normal bowel movement and prevent constipation -It takes weeks to months for recovering the wound. Therefore, advise the patient not to exercise, play sports, or run until healed.

Nursing Management of Orchitis includes:

• Administer analgesic drugs
• Maintain bed rest
• Use ice pack and compression
• Encourage fluid consumption
• Local heat or sitz bath

Nursing Diagnosis of Orchitis includes:

• Acute and chronic pain of the inflamed testis
• Potential anxiety due to future infertility
• Disturbed sleep cycles from discomfort
• Risk of infection

New Research on Orchitis:

-In recent studies, it shows that COVID-19 and SARS-CoV-2 infections and its treatment can affect men's reproductive health, which eventually leads to epididymitis and orchitis. -Those infections, if they lead to testicular endothelial dysfunction then it causes inflammation of the interstitial tissue