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Testicular torsion

Last updated: September 27, 2021

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Testicular torsion is the sudden twisting of the spermatic cord within the scrotum. It most commonly affects neonates and young men. Because of the risk of ischemia and possible infarction of the testis, it is considered a urological emergency. Testicular torsion is characterized by sudden-onset unilateral testicular pain, which may radiate to the lower abdomen, with nausea and vomiting. Clinical findings include a high-riding testis with an absent cremasteric reflex. Imaging with duplex ultrasound of the scrotum may be required if the clinical diagnosis is in doubt. If testicular torsion is suspected, prompt surgical exploration within six hours of symptom onset is essential to salvage the testis. Important differential diagnoses, e.g., orchitis and epididymitis, should be ruled out before initiating treatment.

  • Peak incidence: neonatal period (first 30 days of life) and during puberty (10–14 years) [1]
  • Prevalence
    • 3.8 per 100,000 male individuals under the age of 18 (two-thirds of cases occur between 12 and 18 years of age) [2]
    • Accounts for 10–15% of acute scrotal illness in children within the United States [3]

Epidemiological data refers to the US, unless otherwise specified.

Sudden, severe, unilateral scrotal pain in a patient with a tender, abnormally positioned testis on examination should be managed as testicular torsion until proven otherwise.

References:[3]

Management of testicular torsion is time-sensitive.

  • Perform rapid clinical evaluation of patients with acute scrotal pain as soon as possible.
  • Urgently refer the patient to urology as soon as torsion is suspected (e.g., high clinical likelihood, TWIST score ≥ 6–7). [10][11]
  • Consider imaging for patients with uncertain diagnoses, if this does not delay definitive treatment (see “Diagnostics”). [12]
  • Obtain IV access and start pain management; consider a spermatic cord block.
  • If surgery is not immediately available, consider performing a manual testicular detorsion.
  • Reassess pain frequently until the patient has been taken for exploratory surgery (see “Treatment).

Do not delay urological referral in order to perform imaging or manual detorsion, especially if clinical suspicion is high, as there is a significant risk of infertility and/or testicular loss if definitive surgical management is delayed > 6 hours from symptom onset.

Clinical decision score [10][11][13]

The TWIST score may be used to help guide decisions on imaging prior to surgical exploration.

  • High-risk patients with a score of ≥ 6: extremely high likelihood of torsion
    • Adult patient or child with Tanner stage ≥ 3: Can refer patients directly for surgical exploration without prior imaging.
    • Child with Tanner stage < 3: Consider ultrasound before surgery.
  • Low-risk patients (especially those with a score of 0): very low risk of torsion (ultrasound may not be required, however, this controversial) [10][11][13]
  • Medium-risk patients or clinical uncertainty: Obtain a scrotal ultrasound to help confirm diagnosis.
Testicular workup for ischemia and suspected torsion score (TWIST score) [10][13]
Clinical feature Score if present
Swelling of the scrotum
  • 2
Testis firm to palpation
  • 2
Cremasteric reflex absent
  • 1
Scrotal elevation (high-riding testis)
  • 1
Nausea or vomiting
  • 1

RIsk categories (from original derivation and validation cohort)

  • Low risk: 0–2
  • Medium risk: 3–4
  • High risk: ≥ 5 [10][11][13]

Testicular torsion is typically a clinical diagnosis. Do not delay definitive treatment for diagnostic workup if clinical suspicion is high.

Imaging

Imaging is not routinely indicated in patients in which there is high clinical suspicion but should be considered in patients with atypical clinical features.

Duplex ultrasound of the scrotum [11][14][15][16][17]

Either formal ultrasound or POCUS can be used to diagnose torsion, depending on operator skill and availability. [18]

Other imaging modalities

These are typically time-consuming studies and may not be readily available in emergency situations.

  • Radionuclide imaging [3][19]
    • Indications
    • Characteristic findings
      • Testicular torsion
        • Areas that do not absorb radionuclide as a result of decreased blood flow to the affected testis (“Cold spots”)
        • Asymmetric blood flow
      • Epididymitis: areas where there is increased radionuclide absorption as a result of increased blood flow in inflammation (“Hot spots”)
  • MRI with IV contrast: may be used as an alternative to radionuclide imaging [12]

Surgical intervention is recommended for suspected testicular torsion, regardless of radiological findings.

Laboratory studies

Differential diagnosis of scrotal pain [3]
Disorder History Examination Laboratory studies
Testicular torsion
  • Sudden onset
  • Unilateral painful testis/lower abdomen
  • Nausea or vomiting
Epididymitis
  • Gradual onset (e.g., < 6 weeks if acute, ≥ 6 weeks if chronic) [21]
  • Painful swelling with possible induration
  • Possible history of urethral discharge
  • Fever, dysuria, urinary frequency
Testicular tumor
  • Slow progression (e.g., weeks to months)
  • Usually painless mass (however, the patient may experience a dull ache or describe a “heavy” sensation in the testis)
  • Easy palpation of solid mass
  • Possible manifestations of metastatic disease (e.g., distant lymphadenopathy, chest pain, gastrointestinal symptoms)
  • Possible swelling of the ipsilateral lower limb (venous engorgement due to obstruction)
Torsion of testicular appendage (hydatid of Morgagni)
  • Insidious onset of unilateral scrotal pain
  • Usually seen in boys 3–5 years of age

Torsion of testicular appendage (hydatid of Morgagni) [22]

  • Description: an embryological remnant on the upper pole of the testes or at the epididymis (the remnant of the Mullerian duct) that has the potential to rotate
  • Clinical features: Symptoms resemble acute testicular torsion.
    • Typically seen in boys 3–5 years of age
    • Insidious unilateral scrotal tenderness
    • Blue dot sign (infarction of the hydatid of Morgagni that appears blue through the scrotal skin)
  • Imaging: Doppler ultrasound may show an enlarged testicular appendix and/or mild hydrocele with preserved testicular blood flow.
  • Management
    • A conservative approach with NSAIDs may be considered.
    • If the diagnosis is in doubt, surgical intervention is required to examine the testes.

The differential diagnoses listed here are not exhaustive.

Testicular torsion is a medical emergency and should ideally be treated within 6 hours of the onset of symptoms for the best chance of testicular salvage. Manual detorsion in the emergency department may be attempted prior to surgery for immediate pain relief, but should not delay transferring the patient to the operating room.

Manual testicular detorsion [3][12]

  • Indication: : may be attempted prior to surgery for immediate pain relief or if surgery is not immediately available
  • Procedure
    • Consider performing under ultrasound guidance to increase the likelihood of success.
    • Rotate the testis laterally toward the thigh ; two-thirds of torsions occur toward the midline.
    • If lateral rotation does not provide symptom relief, rotate the testis toward the midline; one-third of torsions occur laterally. [23]
    • Surgery should still be performed in all patients to resolve any possible degree of remaining torsion and to prevent recurrence. [14][14]

Because of the risk of infertility, surgical exploration of the scrotum is recommended in any patient suspected of having testicular torsion, even if manual detorsion has been attempted.

Exploratory surgery [3][14]

  • Examine the patient and consider using the TWIST score to help guide further management.
  • High likelihood of torsion: urgent urology referral without prior imaging
  • Intermediate or low risk: Consider imaging (provided it can be performed rapidly) prior to urology consult.
  • Start pain management with parenteral analgesics.
  • If pain persists and surgery is not immediately available, consider manual testicular detorsion.
  • Urgent transfer to the OR for surgical exploration of the scrotal sac
  • Testicular salvage rates depend on the interval of time between symptom onset and restoration of testicular blood flow. [3][24][25]
    • Within 6 hours: 90–100% [3]
    • > 12 hours: 20–60%
    • > 24 hours: up to 20%
  • Late or absent surgical intervention → testicular ischemia (with/without necrosis) → disruption of the blood-testis barrier formation of antisperm antibodies infertility [24][25]
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