From the Guidelines
Testicular torsion is a urological emergency requiring immediate medical attention, and the classic signs include sudden, severe testicular pain, often accompanied by scrotal swelling, redness, nausea, vomiting, and an abnormal testicular position (higher or horizontal) 1. The affected testicle may be tender to touch, and the cremasteric reflex (elevation of the testicle when the inner thigh is stroked) is typically absent. Management requires urgent surgical intervention within 6 hours of symptom onset to preserve testicular viability, as stated in the most recent guidelines from 2024 1. While awaiting surgery, manual detorsion can be attempted by rotating the testicle outward like opening a book, but this is only a temporary measure. Definitive treatment involves surgical exploration, untwisting of the spermatic cord, and bilateral orchiopexy (fixation of both testicles to prevent recurrence) 2. Delay in treatment significantly increases the risk of testicular loss due to ischemia, as blood flow is compromised when the spermatic cord twists. Testicular torsion occurs most commonly in adolescents and young adults, with the underlying mechanism being abnormal attachment of the testicle within the scrotum, allowing it to rotate freely. Any male with acute testicular pain should be evaluated immediately, as distinguishing torsion from other conditions like epididymitis clinically can be challenging, and the use of ultrasound can aid in diagnosis, with the "whirlpool sign" being a specific indicator of torsion 3. Key points to consider in the management of testicular torsion include:
- Prompt recognition and surgical intervention within 6 hours of symptom onset
- Use of ultrasound to aid in diagnosis, with the "whirlpool sign" being a specific indicator of torsion
- Manual detorsion as a temporary measure while awaiting surgery
- Definitive treatment involving surgical exploration, untwisting of the spermatic cord, and bilateral orchiopexy. It is essential to prioritize the single most recent and highest quality study, which in this case is the 2024 update of the ACR Appropriateness Criteria for acute onset of scrotal pain without trauma or antecedent mass 1.
From the Research
Signs of Testicular Torsion
- Sudden onset of severe unilateral testicular pain
- Nausea and vomiting
- Swollen scrotum
- High-riding testicles
- Absent cremasteric reflex
- Negative Prehn sign 4, 5
Ultrasonographic Features
- Color Doppler ultrasound may reveal a relative decrease or absence of blood flow in the affected testicle
- The most specific ultrasonographic feature is the whirlpool sign of the spermatic cord 4
- Color Doppler ultrasound can confirm complete manual detorsion and ensure restorative flow to the testis 6
Management of Testicular Torsion
- Prompt diagnosis and treatment are necessary for testicular salvage
- Manual detorsion should be performed as soon as possible before surgical intervention
- Manual detorsion is simple, immediately available, and maximizes testis salvage
- Ultrasound guidance can improve the success rate of manual detorsion 4, 7, 6
- Surgical exploration is indicated if history and physical examination suggest torsion, and should not be postponed to perform imaging studies 5
- Doppler ultrasonography can be useful in selected cases with suspected testicular torsion, but should not delay or replace surgery in cases with a strong clinical suspicion 8