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Testicular torsion

Summary

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.

Epidemiology

  • 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.

Etiology

Pathophysiology

Clinical features

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]

Diagnostics

Testicular torsion is typically a clinical diagnosis. Imaging is not routinely indicated but may be considered in patients with atypical clinical features. Because of the significant risk of infertility, diagnostic workup should not delay the management of suspected testicular torsion.

Imaging

  • Duplex ultrasound of the scrotum [10][11][12]
    • Indication: inconclusive clinical findings [10]
    • Characteristic findings [12]
  • Radionuclide imaging [3][13]
    • 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”)

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

Laboratory studies

Differential diagnoses

Differential diagnosis of scrotal pain
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) [14]
  • 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)

  • 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.
  • 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.

References:[3][15]

The differential diagnoses listed here are not exhaustive.

Treatment

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 ER may be attempted prior to surgery for immediate pain relief, but should not delay transferring the patient to the OR.

Exploratory surgery [10][3]

  • Indication: suspected testicular torsion
  • Timing: ideally, within 6 hours of symptom onset [3]
  • Procedure
    • Immediate surgical exploration of the scrotum with reduction (untwisting) and orchidopexy of the affected testis
    • Orchidopexy of the contralateral testis is recommended because the risk of testicular torsion on the contralateral side increases with previous or current testicular torsion.
    • Orchiectomy if the testis is grossly necrotic or nonviable

Manual detorsion [3]

  • Indication: : may be attempted prior to surgery for immediate pain relief or if surgery is not immediately available
  • Procedure
    • 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. [16]
    • Surgery should still be performed in all patients to resolve any possible degree of remaining torsion and to prevent recurrence. [10][10]

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.

Acute management checklist

  • Parenteral analgesics (see acute pain management)
  • Consider imaging if the diagnosis is unclear.
  • Consider manual detorsion.
  • Urgent urology consult for immediate surgical exploration of the scrotal sac

Prognosis

  • Timely intervention within the recommended time period (6 hours from symptom onset) → restoration to previous condition
  • Late or absent surgical intervention → ischemianecrosis of the testicles

References:[4][17]

  • 1. Huang W-Y, Chen Y-F, Chang H-C, Yang T-K, Hsieh J-T, Huang K-H. The incidence rate and characteristics in patients with testicular torsion: a nationwide, population-based study. Acta Paediatr. 2013; 102(8): pp. e363–e367. doi: 10.1111/apa.12275.
  • 2. William P. Adelman, MD, and Alain Joffe, MD, MPH. The adolescent with a painful scrotum. Contemporary Pediatrics. 2000. url: https://www.contemporarypediatrics.com/urology/adolescent-painful-scrotum.
  • 3. Sharp VJ, Arlen AM. Testicular Torsion: Diagnosis, Evaluation, and Management. Am Fam Physician. 2013; 88(12): pp. 835–840. url: http://www.aafp.org/afp/2013/1215/p835.html#abstract.
  • 4. Ringdahl E,Teague L. Testicular Torsion. Am Fam Physician. 2006; 74(10): pp. 1739–1743. url: http://www.aafp.org/afp/2006/1115/p1739.html.
  • 5. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013; 88(12): pp. 835–40. pmid: 24364548.
  • 6. Bombiński P, Warchoł S, Brzewski M, et al. Ultrasonography of Extravaginal Testicular Torsion in Neonates. Polish Journal of Radiology. 2016; 81: pp. 469–472. doi: 10.12659/pjr.897066.
  • 7. Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ. Intermittent Testicular Torsion in the Pediatric Patient: Sonographic Indicators of a Difficult Diagnosis. American Journal of Roentgenology. 2013; 201(4): pp. 912–918. doi: 10.2214/ajr.12.9448.
  • 8. Riaz-ul-haq M, Mahdi DE, Elhassan EU. Neonatal testicular torsion: a review article. Iran J Pediatr. 2012; 22(3): pp. 281–289. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3564080/.
  • 9. Mano R, Livne PM, Nevo A, Sivan B, Ben-meir D. Testicular torsion in the first year of life: characteristics and treatment outcome. Urology. 2013; 82(5): pp. 1132–1137. doi: 10.1016/j.urology.2013.07.018.
  • 10. Ta A et al. Testicular torsion and the acute scrotum. Eur J Emerg Med. 2016; 23(3): pp. 160–165. doi: 10.1097/mej.0000000000000303.
  • 11. Liguori G et al. Role of US in acute scrotal pain. World J Urol. 2011; 29(5): pp. 639–643. doi: 10.1007/s00345-011-0698-8.
  • 12. McDowall J et al. The ultrasonographic “whirlpool sign” in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis. Emerg Radiol. 2018; 25(3): pp. 281–292. doi: 10.1007/s10140-018-1579-x.
  • 13. Wu H-C et al. Comparison of Radionuclide Imaging and Ultrasonography in the Differentiation of Acute Testicular Torsion and Inflammatory Testicular Disease. Clin Nucl Med. 2002; 27(7): pp. 490–493. doi: 10.1097/00003072-200207000-00005.
  • 14. Centers for Disease Control and Prevention. Epididymitis. https://www.cdc.gov/std/tg2015/epididymitis.htm. Updated June 4, 2015. Accessed November 23, 2020.
  • 15. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. 1998; 102(1 Pt 1): pp. 73–76. pmid: 9651416.
  • 16. Lavallee ME, Cash J. Testicular Torsion. Curr Sports Med Rep. 2005; 4(2): pp. 102–104. doi: 10.1097/01.csmr.0000306081.13064.a2.
  • 17. Ogunyemi OI. Testicular Torsion. In: Kim ED. Testicular Torsion. New York, NY: WebMD. http://emedicine.medscape.com/article/2036003. Updated November 23, 2016. Accessed February 2, 2017.
  • Gaillard F et al. Testicular torsion. https://radiopaedia.org/articles/testicular-torsion. Updated April 3, 2017. Accessed April 3, 2017.
  • Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007; 177(1): pp. 297–301. doi: 10.1016/j.juro.2006.08.128.
  • Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2012; 189(5): pp. 1859–1864. doi: 10.1016/j.juro.2012.10.056.
  • Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int. 2003; 92(3): pp. 200–203. doi: 10.1046/j.1464-410x.2003.04307.x.
  • Jacobsen FM, Rudlang TM, Fode M, et al. The Impact of Testicular Torsion on Testicular Function. The World Journal of Men's Health. 2019; 37. doi: 10.5534/wjmh.190037.
last updated 11/26/2020
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