From the Guidelines
Testicular torsion is a medical emergency that requires immediate attention, defined as twisting of the spermatic cord, compromising blood flow to and from the testes, and prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss. Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum, cutting off the blood supply, causing sudden and severe pain and swelling, and it most commonly affects males between 12-18 years old but can occur at any age 1.
Symptoms and Diagnosis
Symptoms of testicular torsion include:
- Sudden, severe pain in one testicle
- Swelling of the scrotum
- Nausea and vomiting
- Abdominal pain
- One testicle positioned higher than the other Diagnosis can be made using ultrasound (US) of the scrotum, which is the established first-line imaging modality for acute scrotal disease, and can be used to diagnose most scrotal disorders when combined with clinical history and physical examination 1.
Treatment and Prognosis
Treatment involves immediate surgery to untwist the spermatic cord and restore blood flow, and this procedure, called orchiopexy, must be performed within 6 hours of symptom onset to save the testicle, with a 90% chance of saving the testicle if treated within this window, and after 12 hours, the chance drops to 50%, and after 24 hours, the testicle will likely need to be removed 1.
Importance of Prompt Action
Understanding the urgency of this condition is crucial, and any sudden testicular pain should be evaluated immediately to prevent potential loss of the testicle and preserve fertility, and a validated clinical risk scoring system, Testicular Workup for Ischemia and Suspected Torsion Score, has shown high positive predictive value, but it has not been widely adopted 1. Some males have an inherited trait that allows the testicle to rotate freely in the scrotum, increasing the risk of torsion, and rapid growth during puberty, physical activity, or injury can trigger the rotation, and US findings in patients with testicular torsion include an enlarged heterogeneous testis that may be hypoechoic, ipsilateral hydrocele, skin thickening, and no color Doppler flow in the testis or spermatic cord 1.
From the Research
Definition and Description
- Testicular torsion is a medical emergency that requires immediate attention and a multidisciplinary approach from emergency, surgical, and radiological services 2.
- It occurs when the spermatic cord, which carries blood to the testicles, twists, reducing blood flow and oxygen to the testicle, leading to tissue death and loss of the testis if not treated promptly 3.
- Testicular torsion is a twisting of the spermatic cord and its contents, affecting 3.8 per 100,000 males younger than 18 years annually 4.
- It is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow, with a key risk factor being the presence of a bell-clapper deformity 5.
Symptoms and Diagnosis
- Patients typically present with severe acute unilateral scrotal pain, nausea, and vomiting 4.
- Physical examination may reveal a high-riding testicle with an absent cremasteric reflex, although the presence or absence of a cremasteric reflex is not a reliable indicator of disease 4, 5.
- Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis 5.
- The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain, but should not be used in isolation 5.
Treatment and Management
- Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum 4.
- Immediate surgical exploration is indicated and should not be postponed to perform imaging studies, with a typically four- to eight-hour window before permanent ischemic damage occurs 4.
- Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED 5.
- Manual detorsion can be attempted in the ED while awaiting transfer or consultation, and US-assisted manual testicular detorsion is a non-invasive, simple, quick, safe, and effective manoeuvre that can rapidly restore testicular blood flow 2.