What is the management of testicular torsion?

Management of Testicular Torsion

Testicular torsion requires immediate surgical exploration within 6-8 hours of symptom onset to prevent permanent testicular loss, and surgery should not be delayed for imaging if clinical suspicion is high. 1

Clinical Presentation and Diagnosis

• Key symptoms and signs:

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

• TWIST Score (Testicular Workup for Ischemia and Suspected Torsion):

  • Points assigned for: testicular swelling, hard testicle, absent cremasteric reflex, nausea/vomiting, high-riding testis
  • High risk: ≥5 points (92.9% positive predictive value) 1
  • Patients with high TWIST scores should proceed directly to urological evaluation rather than imaging 2

Imaging Considerations

• Doppler ultrasound:

  • May be used if diagnosis is uncertain and will not delay surgical intervention 1
  • Includes both grayscale and Doppler examination of bilateral scrotal and inguinal areas 2
  • Key findings: absence of blood flow, "whirlpool sign" (twisted spermatic cord) 2
  • Real-time grayscale imaging can identify a spermatic cord "twist" with 96% sensitivity 2

• Important caveat: Clinical diagnosis is primary, and surgery should never be delayed for imaging when clinical suspicion is high 1, 3

Surgical Management

1. Immediate surgical exploration:

   • Must be performed within 6-8 hours of symptom onset for optimal testicular salvage 2, 1
   • Detorsion of the affected testicle
   • Assessment of testicular viability
   • Bilateral orchiopexy (fixation of both testicles) if the affected testicle is viable 1
   • Orchiectomy if the testicle is non-viable

2. Manual detorsion:

   • Can be attempted when specialty support is not immediately available
   • Involves external rotation of the testicle
   • Blood flow must be confirmed following the maneuver
   • Even if apparently successful, patient should be transferred to specialty care without delay 3

Post-operative Care

• Pain management
• Scrotal support
• Limited physical activity until healing is complete 1

Common Pitfalls to Avoid

1. Misdiagnosis:

   • Mistaking torsion for epididymitis or other less urgent conditions 1
   • Assuming epididymitis in prepubertal males (torsion is more common in this age group) 4

2. Delayed intervention:

   • Waiting for imaging results when clinical suspicion is high 1, 3
   • Relying solely on presence of blood flow on Doppler (partial torsion may still show some flow) 1

3. Failure to consider torsion:

   • Not considering torsion in all patients with acute scrotal pain 1
   • Missing atypical presentations (e.g., traumatic causes, mild pain) 5

Special Considerations

• Neonatal/perinatal torsion:

  • Often extravaginal type
  • May be bilateral (consider contralateral orchiopexy even when unilateral presentation) 6

• Pubertal patients:

  • Extravaginal torsion is rare but possible in pubertal age groups 7
  • Requires the same emergency approach as intravaginal torsion

• Differential diagnosis:

  • Torsion of testicular appendages (most common cause of acute scrotum in prepubertal boys) 2
  • Epididymitis (more common in patients >25 years of age) 2
  • Orchitis

Remember that testicular torsion affects approximately 1 in 4,000 males younger than 25 years annually, and time is of the essence for testicular salvage 4. The 6-8 hour window for intervention is critical, with decreasing chances of salvage as time progresses.