What is the management of testicular or ovarian torsion?

Management of Testicular and Ovarian Torsion

Testicular and ovarian torsion are surgical emergencies requiring immediate intervention within 6-8 hours of symptom onset to prevent permanent gonadal loss. 1, 2

Diagnosis

Testicular Torsion

• Clinical Presentation:

  • Sudden onset of severe unilateral scrotal pain
  • Nausea and vomiting
  • Red, swollen scrotum
  • High-riding testicle
  • Absent cremasteric reflex
  • Pain not relieved with scrotal elevation (negative Prehn sign) 1, 3, 2

• Diagnostic Tools:

  • TWIST score (Testicular Workup for Ischemia and Suspected Torsion) 4:
    • Testicular swelling (2 points)
    • Hard testicle (2 points)
    • Absent cremasteric reflex (1 point)
    • Nausea/vomiting (1 point)
    • High-riding testis (1 point)
    • Low risk: 0-2 points (96.6% negative predictive value)
    • High risk: ≥5 points (92.9% positive predictive value)

• Imaging:

  • Doppler ultrasound if diagnosis is uncertain and doesn't delay surgical intervention 1
  • Important: Do not delay surgical exploration for imaging if clinical suspicion is high 1, 2

Ovarian Torsion

• Clinical Presentation:

  • Sudden onset of severe unilateral lower abdominal/pelvic pain
  • Nausea and vomiting
  • Adnexal tenderness on examination 1, 5

• Diagnostic Tools:

  • Combined transabdominal and transvaginal ultrasound with Doppler 1
  • Ultrasound findings:
    • Enlarged ovary
    • Absent or decreased blood flow
    • Whirlpool sign (twisted vascular pedicle)
    • Free fluid in pelvis 1

Management

Testicular Torsion

1. Immediate Surgical Exploration:

   • Urgent scrotal exploration within 6-8 hours of symptom onset 1, 2
   • Manual detorsion may be attempted while preparing for surgery but should not delay definitive treatment 6

2. Surgical Procedure:

   • Detorsion of the affected testicle
   • Assessment of testicular viability
   • Bilateral orchiopexy (fixation of both testicles) if the affected testicle is viable 1, 7
   • Orchiectomy if the testicle is non-viable 2

3. Post-operative Care:

   • Pain management
   • Scrotal support
   • Limited physical activity until healing is complete 3

Ovarian Torsion

1. Immediate Surgical Intervention:

   • Laparoscopy or laparotomy without delay 5
   • Important: Do not delay surgical intervention for definitive imaging diagnosis 5

2. Surgical Procedure:

   • Detorsion of the affected ovary
   • Assessment of ovarian viability
   • Removal of any adnexal masses if present
   • Oophoropexy (fixation of the ovary) may be considered to prevent recurrence 1, 5

3. Post-operative Care:

   • Pain management
   • Limited physical activity until healing is complete

Special Considerations

Differential Diagnosis

• Testicular Conditions:

  • Epididymitis/orchitis
  • Strangulated inguinal hernia
  • Testicular trauma
  • Testicular tumor
  • Torsion of testicular appendage 1, 3

• Ovarian Conditions:

  • Ectopic pregnancy (rule out with β-hCG)
  • Pelvic inflammatory disease
  • Ruptured ovarian cyst
  • Appendicitis 1

Critical Points

1. Time is Tissue: The 6-8 hour window for intervention is critical for gonadal salvage 1, 2
2. Clinical Diagnosis: Torsion is primarily a clinical diagnosis; don't delay surgery for imaging 1, 2
3. Bilateral Fixation: In testicular torsion, both testicles should be fixed to prevent contralateral torsion 7
4. Fertility Impact: Delayed treatment may result in decreased fertility 2
5. Disparity in Care: Studies show that ovarian torsion is often diagnosed and treated later than testicular torsion, resulting in lower salvage rates (14.4% vs 30.3%) 5

Pitfalls to Avoid

• Mistaking torsion for epididymitis or other less urgent conditions
• Delaying surgical intervention while waiting for imaging
• Failing to consider torsion in all patients with acute scrotal or lower abdominal pain
• Relying solely on the presence of blood flow on Doppler to rule out torsion (partial torsion may still show some flow) 1