Testicular Torsion and Subsequent Testicular Function in Young Men From the General Population

A.H. Hansen; L. Priskorn; L.S. Hansen; E. Carlsen; U.N. Joensen; F.M. Jacobsen; C.F.S. Jensen; N. Jørgensen

Hum Reprod. 2023;38(2):216-224.

Abstract and Introduction

Abstract

Study Question: Is prior testicular torsion associated with testicular function (semen quality and reproductive hormones) in young men from the general population?

Summary Answer: In young men from the general population, no differences in semen parameters were observed in those who had experienced testicular torsion compared to controls and observations of higher FSH and lower inhibin B were subtle.

What is Known Already: Testicular function may be impaired after testicular torsion, but knowledge is sparse and based on studies with small sample sizes and no control group or a less than ideal control group.

Study Design, Size, Duration: A cross-sectional population-based study was carried out including 7876 young Danish men with unknown fertility potential, examined from 1996 to 2020.

Participants/Materials, Setting, Methods: All men (median age 19.0 years) had a physical examination, provided a blood and semen sample, and filled in a questionnaire including information about prior testicular torsion, birth, lifestyle and current and previous diseases. Markers of testicular function, including testis volume, semen parameters and reproductive hormones, were compared between men operated for testicular torsion and controls, using multiple linear regression analyses.

Main Results and the Role of Chance: The average participation rate was 24% for the entire study period. In total, 57 men (0.72%) were previously operated for testicular torsion (median age at surgery 13.4 years) of which five had only one remaining testicle. Men with prior testicular torsion were more often born preterm (25% versus 9.5% among controls), and they had significantly higher FSH and lower inhibin B levels, and a lower inhibin B/FSH ratio than controls in crude and adjusted models. The association was mainly driven by the subgroup of men who had undergone unilateral orchiectomy. No differences in semen parameters were observed.

Limitations, Reasons for Caution: A limitation is the retrospective self-reported information on testicular torsion. Also, results should be interpreted with caution owing to the high uncertainty of the observed differences.

Wider Implications of the Findings: Overall, the results of our study are reassuring for men who have experienced testicular torsion, especially when treated with orchiopexy, for whom reproductive hormone alterations were subtle and without obvious clinical relevance. Our study found no differences in semen parameters, but follow-up studies are needed to assess any long-term consequences for fertility.

Study Funding/Competing Interest(S): Financial support was received from the Danish Ministry of Health; the Danish Environmental Protection Agency; the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603, FP7/2007-2013, DEER Grant agreement no. 212844); A.P. Møller and wife Chastine Mckinney Møllers Foundation; Svend Andersens Foundation; the Research Fund of the Capital Region of Denmark; and ReproUnion (EU/Interreg). The authors have nothing to declare.

Trial Registration Number: N/A.

Introduction

Testicular torsion is an emergency condition that results from twisting of the spermatic cord, causing a decrease in arterial blood flow to the testis. Untreated, this can lead to ischemia of the testis (Sharp et al., 2013). Eighty percent of testicular torsion cases happen because of a bell-clapper deformity of the tunica vaginalis (Favorito et al., 2004). Testicular torsion has a bimodal age distribution with peak occurrences in newborns and pubertal boys (Yang et al., 2011; Zhao et al., 2011). Men under 18 years account for 90% of all cases (Zhang et al., 2020).

Testicular torsion is treated surgically by detorsion of the spermatic cord followed by orchiopexy or, in cases with irreversible testicular tissue necrosis, removal of the involved testis (Tekül et al., 2016). Evidence points toward an association between testicular torsion and reduced testicular function with altered hormone profiles and impaired semen quality, despite treatment (Thomas et al., 1984; Romeo et al., 2010). Furthermore, it has been indicated that the contralateral unaffected testis has abnormalities, such as atrophy of the Leydig cells and spermatogenetic maturation arrest (Laor et al., 1990; Hagen et al., 1992), although the etiology is not well understood (Jacobsen et al., 2020).

Current knowledge of the potential impact of testicular torsion on testicular function in adult life is based on studies with a small sample size, consisting of case series of patients with testicular torsion without a control group, or with the inclusion of a control group consisting of a selected population of proven fertile men or semen donors who are assumed to have a better testicular function than men from the general population. Thus, the association has not yet been investigated in an unselected population with no knowledge of their fertility status. In this cross-sectional study, the objective was to investigate the association between previous testicular torsion and current testicular function, assessed by measuring testis volume, reproductive hormones, and semen parameters in almost 8000 young men from the general population in Denmark.

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Abstract and Introduction
Material and Methods
Results
Discussion
References

Table I. Characteristics of young Danish men from the general population with or without testicular torsion.
	n	Operated for testicular torsion (Cases: n = 57) Median (5–95 percentiles)	n	No testicular torsion (Controls: n = 7819) Median (5–95 percentiles)	P-value
Age (years)	56	19.0 (18.3–21.7)	7771	19.0 (18.4–22.1)	0.76^#
Age at operation, torsion (years)	52	13.4 (7.5–19.9)	—	—	—
Height (cm)	57	181.3 (171.0–190.2)	7748	181.5 (170.8–192.6)	0.56^#
Weight (kg)	57	72.2 (55.3–116.7)	7747	73.5 (59.0–95.4)	0.37^#
BMI (kg/m ² )	57	21.8 (17.9–33.7)	7711	22.3 (18.5–28.6)	0.39^#
Alcohol consumption (units, recent week) ^a	57	6.0 (0.0–33.4)	7597	10.0 (0.0–37.0)	0.55^#
Smokers	57	43.9%	7747	45.1%	0.85*
No. of cigarettes/day, smokers	25	7.0 (0.0–18.5)	3406	7.0 (0.1–20.0)	0.57^#
Ejaculation abstinence time (h)	57	66 (47–194)	7735	62 (36–144)	0.27^#
Operated for hypospadias	57	1.8%	7788	0.1%	<0.001*
History of cryptorchidism	51	19.6%	6889	7.9%	0.002*
Born premature	44	25.0%	5543	9.5%	0.001*
Birthweight	48		6443		<0.001*
<2500 g		18.8%		5.5%
2500–5000 g		81.2%		89.8%
>5000 g		0.0%		4.7%

Data are presented as medians (5–95 percentiles) or frequencies and test-statistics (P-value).
^#Mann–Whitney U-test and
*Pearson χ² test.
^aUnits alcohol consumed the week before study examination.

Table II. Reproductive hormone levels in young Danish men with or without a prior operation for testicular torsion.
	n	Raw values	Unadjusted	Adjusted model 1		Adjusted model 2
	n	Median (5–95 percentile)	β (95% CI), % difference	n	β (95% CI), % difference	n	β (95% CI), % difference
FSH (IU/l)
No testicular torsion	7723	2.6 (1.0–6.6)	Ref.	7693	Ref.	5450	Ref.
Testicular torsion	56	3.1 (1.1–8.6)	20.9 (2.5; 42.1)	55	20.9 (2.1; 41.9)	42	22.1 (1.0; 46.8)
LH (IU/l)
No testicular torsion	7731	3.4 (1.6–6.5)	Ref.	7701	Ref.	5457	Ref.
Testicular torsion	56	3.6 (1.5–6.7)	4.1 (−9.0; 18.5)	55	5.1 (−7.4; 19.8)	42	7.3 (−7.1; −24.6)
Inhibin B (pg/ml)
No testicular torsion	7721	183.0 (90.0–323.0)	Ref.	7691	Ref.	5449	Ref.
Testicular torsion	56	171.0 (65.7–315.7)	−11.3 (−20.9; −0.2)	55	−11.3 (−21.2; −0.3)	42	−18.9 (−28.8; −7.5)
Testosterone (nmol/l)
No testicular torsion	7721	20.3 (11.9–32.9)	Ref.	7691	Ref.	5453	Ref.
Testicular torsion	56	19.5 (11.7–36.1)	−2.0 (−9.9; 7.1)	55	−2.0 (−9.8; 7.0)	42	−3.9 (−12.6; 6.4)
SHBG (nmol/l)
No testicular torsion	7729	29.0 (14.0–50.8)	Ref.	7699	Ref.	5457	Ref.
Testicular torsion	56	27.2 (15.0–50.1)	−3.9 (−13.2; 7.3)	55	−3.9 (−13.9; 6.5)	42	−5.2 (−16.1; 10.2)
Estradiol (pmol/l)
No testicular torsion	7682	82.0 (44.0–136.0)	Ref.	7652	Ref.	5423	Ref.
Testicular torsion	56	85.0 (34.0–152.1)	−2.0 (−11.4; 9.2)	55	−1.0 (−11.2; 9.5)	42	−3.0 (−14.1; 10.2)
Inhibin B/FSH ratio
No testicular torsion	7719	71.1 (16.6–265.5)	Ref.	7689	Ref.	5447	Ref.
Testicular torsion	56	60.0 (8.9–194.6)	−26.7 (−42.1; −6.9)	55	−26.7 (−42.2; −6.3)	42	−33.6 (−49.2; −12.5)
Testosterone/LH ratio
No testicular torsion	7719	6.1 (2.8–12.4)	Ref.	7689	Ref.	5451	Ref.
Testicular torsion	56	5.7 (2.7–12.5)	−5.8 (−17.6; 8.0)	55	−6.8 (−18.4; 7.3)	42	−10.4 (−23.1; 4.7)

Raw data are presented as medians (5–95 percentiles), and results from the linear regression analyses are presented as β-estimates (95% CI). Owing to the ln-transformation of reproductive hormones when entering the regression analyses, the results have been back transformed to reflect the percentage differences. SHBG, sex hormone-binding globulin.
Model 1: Adjusted for time of blood sampling.
Model 2: As model 1 with additional adjustment for prematurity.

Table III. Semen parameters in young Danish men with or without a prior operation for testicular torsion.
	n	Raw values	Unadjusted	Adjusted model 1		Adjusted model 2
	n	Median (5–95 percentile)	β (95% CI)	n	β (95% CI)	n	β (95% CI)
Total testis volume, palpation (ml)
No testicular torsion	7618	40 (26–58)	Ref.	—	—	5411	Ref.
Testicular torsion	48	40 (21–58)	−0.072 (−2.92; 2.78)			38	0.62 (−2.56; 3.79)
Total testis volume, ultrasound (ml) ^a
No testicular torsion	7507	28 (17–43)	Ref.	—	—	5326	Ref.
Testicular torsion	47	27 (12–41)	−0.05 (−1.31; 0.03)			38	−0.06 (−0.16; 0.03)
Semen volume (ml) ^a
No testicular torsion	7763	3.2 (1.3–6.0)	Ref.	7725	Ref.	5483	Ref.
Testicular torsion	57	3.4 (1.3–6.9)	0.024 (−0.03; 0.08)	57	0.023 (−0.035; 0.080)	44	0.025 (−0.040; 0.090)
Sperm concentration (million/ml) ^a
No testicular torsion	7763	45 (3–161)	Ref.	7725	Ref.	5482	Ref.
Testicular torsion	57	39 (0.3–165)	−0.22 (−0.53; 0.09)	57	−0.23 (−0.54; 0.09)	44	−0.42 (−0.77; −0.063)
Total sperm count (million) ^a
No testicular torsion	7753	141 (9–522)	Ref.	7715	Ref.	5476	Ref.
Testicular torsion	57	147 (0.9–456)	−0.24 (−0.71; 0.23)	57	−0.25 (−0.72; 0.22)	44	−0.50 (−1.03; 0.044)
Progressive sperm motility (%) ^b
No testicular torsion	7720	61 (24–79)	Ref.	7539	Ref.	5356	Ref.
Testicular torsion	56	59 (26–81)	−215 (−667; 234)	54	−195 (−654; 263)	43	−301 (−812; 210)
Normal sperm morphology (%) ^c
No testicular torsion	7540	6.5 (1.0–16.0)	Ref.	7502	Ref.	5321	Ref.
Testicular torsion	55	6.5 (0.8–15.0)	−0.11 (−0.37; 0.15)	55	−0.11 (−0.37; 0.15)	42	−0.12 (−0.41; 0.18)

Raw data are presented as medians (5–95 percentiles) and results from the linear regression analyses are presented as β-estimates (95% CI); results from the latter should be interpreted on the transformed scale.
^aCubic root transformed.
^bSecond potency transformed.
^cSquare root transformed.
Model 1: Adjusted for ejaculation abstinence time (h), except for the total testis volumes, where adjustments are redundant. Progressive sperm motility was additionally adjusted for time between sampling and analysis (min).
Model 2: As model 1 with additional adjustment for prematurity.

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Testicular Torsion and Subsequent Testicular Function in Young Men From the General Population

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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