What is the immediate course of action for a 25-year-old male with symptoms of testicular torsion?

From the Guidelines

The immediate course of action for a 25-year-old male with symptoms of testicular torsion is emergency surgical intervention within 6 hours of symptom onset. The patient should go to the nearest emergency department immediately without delay. While awaiting surgery, pain management with analgesics may be provided, but this should not delay definitive treatment. Manual detorsion may be attempted by a physician in the emergency setting by rotating the affected testicle outward (like opening a book), but this is only a temporizing measure and not a substitute for surgery. During surgery, the affected testicle will be untwisted and fixed to the scrotal wall (orchiopexy) to prevent recurrence. The contralateral testicle is typically also fixed preventatively. Prompt treatment is critical because testicular torsion cuts off blood supply to the testicle, and after 6 hours of ischemia, the risk of testicular loss increases significantly, reaching nearly 100% at 24 hours, as highlighted in the 2024 update of the ACR Appropriateness Criteria for acute onset of scrotal pain without trauma or antecedent mass 1. Delaying treatment or mistaking the symptoms for less urgent conditions like epididymitis can result in testicular necrosis and loss of the organ, potentially affecting fertility and requiring orchiectomy (testicle removal).

Some key points to consider in the diagnosis and management of testicular torsion include:

• The clinical presentation of testicular torsion can overlap with other conditions such as epididymitis and torsion of the testicular appendage, making prompt and accurate diagnosis essential 1.
• A validated clinical risk scoring system, the Testicular Workup for Ischemia and Suspected Torsion Score, has shown high positive predictive value but has not been widely adopted 1.
• The European Association of Urology guidelines on urological infections provide an algorithm for the diagnosis and treatment of epididymitis, which may be useful in distinguishing this condition from testicular torsion 1.
• However, in cases of suspected testicular torsion, emergency surgical intervention should not be delayed while awaiting further diagnostic evaluation or attempting manual detorsion, as the window for successful treatment is limited to 6-8 hours after symptom onset 1.

In terms of PANCE style board questions, here are 20 potential questions that could be relevant to this topic:

• What is the most common cause of acute scrotal pain in adolescent boys and adults?
• What is the estimated yearly incidence of testicular torsion in boys under 18 years of age?
• What is the recommended treatment for a patient with suspected testicular torsion?
• What is the purpose of orchiopexy in the treatment of testicular torsion?
• How does the clinical presentation of testicular torsion differ from that of epididymitis?
• What is the role of manual detorsion in the treatment of testicular torsion?
• What are the potential consequences of delaying treatment for testicular torsion?
• How does the Testicular Workup for Ischemia and Suspected Torsion Score aid in the diagnosis of testicular torsion?
• What is the recommended antibiotic regimen for the treatment of epididymitis?
• How does the European Association of Urology guidelines on urological infections approach the diagnosis and treatment of epididymitis?

From the Research

Immediate Course of Action for Testicular Torsion

The immediate course of action for a 25-year-old male with symptoms of testicular torsion includes:

• Prompt recognition and treatment to salvage the testicle 2
• Immediate surgical exploration if history and physical examination suggest torsion, without postponing to perform imaging studies 2
• Examination for a high-riding testicle with an absent cremasteric reflex 2

Diagnostic Features

Diagnostic features of testicular torsion include:

• Severe acute unilateral scrotal pain 2
• Nausea and vomiting 2, 3
• Horizontal lie of the testes on examination, associated with the bell-clapper deformity 3

Management Outcomes

Management outcomes for testicular torsion include:

• Orchiectomy or orchiopexy as treatment options 4
• Wait time to surgery positively correlating with orchiectomy 4
• Early identification and intervention vital to testicular salvage 4
• Surgical fixation of the testes resulting in pain relief in the majority of patients with intermittent testicular torsion 3

Important Considerations

Important considerations in the management of testicular torsion include:

• The chance of salvaging the testicle declines with time and degree of torsion 4
• Delay in treatment may be associated with decreased fertility or necessitate orchiectomy 2
• The presence of the bell-clapper deformity may moderate the relationship between temperature and testicular torsion 4