From the Guidelines
The recommended treatment for suspected testicular torsion is immediate surgical exploration and detorsion, ideally within 6 hours of symptom onset. This is a true urologic emergency requiring prompt referral to the emergency department for urological consultation 1. While awaiting surgery, manual detorsion can be attempted by rotating the affected testicle outward (like opening a book) to potentially restore blood flow, but this should not delay definitive surgical management. The urgency of treatment is based on the fact that torsion cuts off blood supply to the testicle, causing ischemia that can lead to permanent damage and necrosis if not promptly corrected.
Key Considerations
- Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss 1.
- 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.
- US 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.
- The sensitivity and specificity of color Doppler US for the detection of testicular torsion is variable, with reports ranging from 69% to 96.8% and 87% to 100%, respectively 1.
Surgical Management
During surgery, the affected testicle is untwisted to restore blood flow, and both testicles are typically fixed to the scrotal wall (orchiopexy) to prevent recurrence. If the testicle is found to be nonviable due to prolonged ischemia, an orchiectomy (removal) may be necessary. Delay in treatment significantly increases the risk of testicular loss, with salvage rates dropping dramatically after 6 hours and becoming very low after 24 hours.
Pain Management
Pain management with analgesics is appropriate while awaiting surgery, but no medication can replace the need for surgical intervention. The goal is to manage pain while promptly addressing the underlying cause of the pain, which is the torsion of the testicle.
Diagnostic Challenges
The diagnosis of testicular torsion can be challenging due to the variable presentation of symptoms and the overlap with other conditions such as epididymitis. However, the use of clinical scoring systems and imaging modalities like US can help in making an accurate diagnosis. It is crucial to integrate clinical data, including the presence of fever, waxing and waning pain, and laboratory markers for infection, to distinguish between testicular torsion and other conditions like epididymoorchitis 1.
From the Research
Recommended Treatment for Suspected Testicular Torsion
The recommended treatment for suspected testicular torsion is immediate surgical intervention, as delayed treatment can result in loss of the testicle and potential long-term complications.
- Immediate consultation with a urologist, pediatric surgeon, or general surgeon is necessary when a patient presents with acute scrotal pain and physical findings do not permit confident exclusion of testicular torsion 2.
- Manual detorsion may be indicated when specialty support is not immediately available, but even if this technique is apparently successful, the patient should be transferred to specialty care without delay 2.
- Manual detorsion is simple, immediately available, and maximizes testis salvage, and a successful maneuver permits nonemergency orchiopexy 3.
- An algorithm for the management of testicular torsion that includes an attempt of manual detorsion prior to surgery is proposed 3.
Importance of Prompt Treatment
Prompt treatment is crucial in cases of suspected testicular torsion, as delayed treatment can result in:
- Loss of the testicle 4, 5, 3
- Potential long-term complications 4, 5
- Inaccurate assessment of the contralateral testis through physical examination and imaging in cases of perinatal torsion 5
Surgical Intervention
Surgical intervention is necessary in cases of suspected testicular torsion, and: