Treatment for Testicular Torsion
Testicular torsion requires immediate surgical intervention within 6-8 hours of symptom onset to prevent testicular loss. 1 This condition represents a true urological emergency that demands rapid diagnosis and treatment to preserve testicular viability.
Diagnosis
Clinical Presentation
- Sudden onset of severe unilateral testicular pain
- Testicular swelling and tenderness
- High-riding or abnormally positioned testis
- Nausea and vomiting (common)
- Absent cremasteric reflex (most accurate clinical sign) 2
- Pain not relieved by elevation of the scrotum (negative Prehn sign) 1
Diagnostic Evaluation
- Color Doppler ultrasound is the preferred imaging modality
- Findings: Decreased or absent blood flow to the affected testis
- TWIST score (Testicular Workup for Ischemia and Suspected Torsion) can aid diagnosis 3
- Components: testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1)
- High score (≥5) has 92.86% positive predictive value for torsion 3
Treatment Algorithm
Immediate Urological Consultation
- Do not delay surgical consultation if torsion is suspected 4
Manual Detorsion
- Can be attempted while awaiting surgery
- External rotation of the testis (typically outward "open book" direction)
- Must confirm restoration of blood flow after the maneuver 2
- Not a substitute for definitive surgical management
Emergency Surgical Exploration
- Must be performed within 6-8 hours of symptom onset for best outcomes 1
- Procedure includes:
- Detorsion of the affected testis
- Assessment of testicular viability
- Orchiopexy (fixation) of the affected testis if viable
- Prophylactic orchiopexy of the contralateral testis 2
- Orchiectomy if the testis is nonviable
Adjunctive Measures
- Pain management
- Scrotal elevation
- Anti-inflammatory medications
Critical Time Considerations
The viability of the testis is time-dependent:
- Within 6 hours: >90% salvage rate
- 6-12 hours: 50-70% salvage rate
12 hours: <20% salvage rate 2
Differential Diagnosis Considerations
Testicular torsion must be distinguished from:
- Epididymitis (more common in adults >35 years) 1
- Torsion of testicular appendage (more common in prepubertal boys) 1
- Trauma-induced torsion (rare but reported) 5
Special Populations
- Neonates: Bilateral torsion is more frequently reported; immediate surgical intervention recommended 6
- Children: Consider torsion in all cases of acute scrotal pain until proven otherwise 2
- Adults: Though less common in adults, torsion should still be considered in the differential diagnosis of acute scrotal pain
Remember that clinical examination alone may be insufficient, and normal ultrasound findings cannot completely exclude the diagnosis of testicular torsion 4. When in doubt, surgical exploration is warranted to prevent potential testicular loss.