What is the recommended treatment for suspected testicular torsion?

Management of Suspected Testicular Torsion

Immediate surgical exploration is the recommended treatment for suspected testicular torsion as it is a surgical emergency requiring intervention within 6-8 hours of symptom onset to prevent testicular loss. 1

Clinical Presentation and Diagnosis

• Key clinical features:

  • Sudden onset of severe unilateral testicular pain
  • Testicular swelling and tenderness
  • Nausea and vomiting (common)
  • Absence of fever (unlike epididymitis)
  • Negative Prehn's sign (pain not relieved by elevation of testicle) 1

• Diagnostic approach:

  • Testicular torsion must be considered in all cases of acute scrotal pain, especially in adolescents 1
  • If clinical suspicion is high, proceed directly to surgical exploration without imaging 1
  • For equivocal cases, color Doppler ultrasound is the imaging modality of choice with sensitivity of 96-100% and specificity of 84-95% 1
  • Look for the "whirlpool sign" on ultrasound (twisted spermatic cord) which has 96% sensitivity and 99% specificity 1

Treatment Algorithm

1. High clinical suspicion of testicular torsion:

   • Immediate urological consultation
   • Proceed directly to surgical exploration without delay
   • Do not wait for imaging if clinical presentation is classic 1

2. Moderate clinical suspicion:

   • Urgent color Doppler ultrasound if it can be performed without significant delay
   • If ultrasound shows absent or decreased blood flow, proceed to surgery
   • If ultrasound is unavailable or will cause delay, proceed to surgical exploration 1

3. While awaiting definitive treatment:

   • Manual detorsion can be attempted by external rotation of the testis
   • Rotate the testicle outward (like opening a book)
   • Confirm restoration of blood flow after the maneuver
   • This is a temporizing measure only and does not replace surgical intervention 2

Surgical Management

• Surgical exploration provides definitive treatment:
  • Detorsion of the affected testicle
  • Assessment of testicular viability
  • Orchiopexy (fixation) of the affected testicle if viable
  • Prophylactic orchiopexy of the contralateral testicle (to prevent future torsion) 2
  • Orchiectomy if the testicle is nonviable

Time Sensitivity

• Critical time window:
  • Testicular salvage rates:

    • 90% if surgery within 6 hours

    • 50% if surgery within 12 hours
    • <10% if surgery after 24 hours 1, 3

Differential Diagnosis

• Epididymitis/epididymo-orchitis:

  • More common in men >35 years
  • Gradual onset of pain
  • Often associated with urinary symptoms
  • Positive Prehn's sign (pain relief with scrotal elevation)
  • Treatment: antibiotics (ceftriaxone plus doxycycline) 1, 4

• Torsion of testicular appendage:

  • Most common in prepubertal boys
  • "Blue dot sign" may be visible (21% of cases)
  • Less severe pain than testicular torsion
  • Treatment: symptomatic management or surgical removal 1, 2

Common Pitfalls to Avoid

1. Delaying surgical intervention while waiting for diagnostic tests
2. Misdiagnosing as epididymitis in young males (testicular torsion is more common in adolescents)
3. Relying on absence of cremasteric reflex as a definitive sign (not reliable)
4. Failing to consider torsion in patients with atypical presentations (e.g., back pain) 5
5. Assuming normal ultrasound excludes torsion (false negatives can occur) 3

Remember that testicular torsion is a time-sensitive surgical emergency. When in doubt, surgical exploration is preferred over observation, as the consequences of missed torsion (testicular loss) are more severe than the risks of negative exploration.