What is the recommended treatment for suspected testicular torsion?

Treatment for Suspected Testicular Torsion

Suspected testicular torsion requires immediate surgical exploration within 6-8 hours of symptom onset to prevent permanent gonadal loss. 1

Diagnosis

• Clinical Presentation:

  • Sudden onset of severe unilateral scrotal or lower abdominal/pelvic pain
  • Nausea and vomiting
  • Physical exam findings: testicular swelling, hard testicle, absent cremasteric reflex, high-riding testis 1, 2

• TWIST Score can assess risk of testicular torsion:

  • Points assigned for: testicular swelling, hard testicle, absent cremasteric reflex, nausea/vomiting, high-riding testis
  • Score ≥5 points has 92.9% positive predictive value for torsion 1
  • Note: The finding of an ipsilateral absent cremasteric reflex is the most accurate sign 3

• Imaging:

  • Doppler ultrasound should only be used if it won't delay surgical intervention
  • Key findings: absence of blood flow and "whirlpool sign" (twisted spermatic cord)
  • Sensitivity of color Doppler US: 69-96.8% 1
  • Real-time grayscale imaging can identify spermatic cord "twist" with 96% sensitivity 1

Management Algorithm

1. Immediate Urological Consultation

   • Do not delay surgical consultation if torsion is suspected 2
   • All prepubertal and young adult males with acute scrotal pain should be considered to have testicular torsion until proven otherwise 3

2. While Awaiting Surgery:

   • Manual detorsion can be attempted in the emergency department
   • Technique: external rotation of the testis (typically outward "open book" direction)
   • Must confirm restoration of blood flow following the maneuver 3
   • Provide pain management

3. Definitive Treatment: Surgical Exploration

   • Approach: detorsion of affected testicle
   • Assessment of testicular viability
   • Bilateral orchiopexy if affected testicle is viable
   • Orchiectomy if testicle is non-viable 1

Timing Considerations

• Surgical intervention is most effective within 6-8 hours of symptom onset 1
• Optimal time frame is less than 6 hours after onset of symptoms 3
• Testicular salvage rates decrease significantly after this window

Post-Operative Care

• Pain management
• Scrotal support
• Limited physical activity until healing is complete
• Monitoring for complications including testicular atrophy (9.1-47.5%) 1

Common Pitfalls and Caveats

1. Diagnostic Delays:

   • Atypical presentation with back pain can lead to misdiagnosis 4
   • Always examine testicles in young males with back pain

2. Imaging Limitations:

   • A normal ultrasound examination cannot exclude the diagnosis 2
   • Never delay surgical exploration for imaging if clinical suspicion is high

3. Bilateral Involvement:

   • Bilateral torsion is being more frequently reported
   • Assessment of the contralateral testis through physical examination and imaging can be inaccurate 5

4. Surgical Considerations:

   • Surgical trainees are more likely to fix a normal testicle than urology trainees 6
   • Best practice includes bilateral orchiopexy even when only one side is affected 1
   • Potential complications of testicular fixation include chronic pain and infertility 6

5. Differential Diagnosis:

   • Torsion of the appendix testis (more common in children) - may present with "blue dot sign"
   • Epididymitis/orchitis (uncommon in prepubertal males) 3

Remember that testicular torsion is a true surgical emergency, and time to treatment directly impacts testicular salvage rates. When in doubt, proceed to surgical exploration rather than observation.