What is the treatment for testicular (testis) torsion?

Treatment of Testicular Torsion

Testicular torsion is a surgical emergency requiring immediate surgical exploration and detorsion to preserve testicular viability, with the best outcomes achieved when surgery is performed within 6 hours of symptom onset. 1

Diagnosis

Prompt diagnosis is critical for testicular salvage. Key diagnostic features include:

• Clinical presentation:

  • Sudden onset of severe scrotal pain
  • High-riding testis
  • Absent cremasteric reflex
  • Nausea/vomiting
  • No pain relief with testicular elevation (negative Prehn sign) 2

• Imaging:

  • Doppler ultrasound is essential - shows decreased or absent blood flow in the affected testis 2, 3
  • The TWIST Score can help assess risk (testicular swelling, hard testicle, absent cremasteric reflex, nausea/vomiting, high-riding testis) - score ≥5 has 92.9% positive predictive value for torsion 2

Treatment Algorithm

1. Immediate surgical intervention:

   • Emergency scrotal exploration
   • Manual detorsion of the affected testis
   • Assessment of testicular viability
   • Bilateral orchiopexy to prevent recurrence 1, 4

2. Timing is critical:

   • Best outcomes when surgery is performed within 6 hours of symptom onset
   • Testicular salvage rates decrease dramatically after 6 hours
   • Even with delayed presentation, surgical exploration is indicated as some testicular tissue may remain viable 1

3. Manual detorsion:

   • May be attempted while preparing for surgery
   • Not a substitute for definitive surgical management
   • Performed by rotating the testis outward (like opening a book) 3

4. Post-operative management:

   • Scrotal support
   • Pain management
   • Monitoring for complications 2

Special Considerations

• Bilateral torsion:

  • Rare but devastating complication
  • Immediate surgical intervention is mandatory
  • Even severely compromised testes should be preserved when possible as some endocrine function may be retained 5

• Differential diagnosis:

  • Epididymitis - gradual onset, positive Prehn sign, increased blood flow on Doppler
  • Torsion of testicular appendages - can be treated conservatively
  • Strangulated inguinal hernia
  • Testicular trauma 2, 3, 6

Complications and Outcomes

• Potential complications:

  • Testicular atrophy (9.1% to 47.5%)
  • Infertility
  • Abnormal exocrine function even after successful unilateral detorsion 2, 4

• Long-term follow-up:

  • Regular monitoring for testicular atrophy
  • Fertility assessment may be indicated in cases of bilateral involvement or delayed treatment 2

Pitfalls to Avoid

• Delaying surgical intervention while waiting for diagnostic tests - if clinical suspicion is high, proceed directly to surgery
• Misdiagnosing as epididymitis - testicular torsion has sudden onset and absent cremasteric reflex
• Inadequate follow-up - patients should be monitored for testicular atrophy and fertility issues
• Failure to perform bilateral orchiopexy - contralateral testis is at risk for future torsion due to anatomical predisposition 2, 4

Remember that testicular torsion is one of the few true urological emergencies. When in doubt, surgical exploration is warranted as the consequences of missed torsion are severe and irreversible.