For acute testicular torsion, do you recommend Doppler (ultrasound) or surgical exploration?

Management of Acute Testicular Torsion: Doppler vs. Surgical Exploration

For acute testicular torsion, immediate surgical exploration is recommended over Doppler ultrasound when there is high clinical suspicion, as time to detorsion is the most critical factor in testicular salvage. 1

Clinical Assessment and Decision Making

High Clinical Suspicion (Immediate Surgery)

When clinical suspicion for testicular torsion is high, patients should proceed directly to surgical exploration without imaging:

• Sudden onset of severe scrotal pain
• Absence of cremasteric reflex
• High-riding or abnormally positioned testicle
• In pediatric patients, high TWIST (Testicular Workup for Ischemia and Suspected Torsion) scores warrant immediate urological evaluation rather than imaging 1

Intermediate or Low Clinical Suspicion (Role for Doppler)

Doppler ultrasound is appropriate in cases with:

• Equivocal clinical presentation
• Low or intermediate TWIST scores in pediatric patients
• Gradual onset of pain (more suggestive of epididymitis)
• Normal testicular position

Diagnostic Performance of Doppler Ultrasound

• Sensitivity: 96-100% for detecting torsion
• Specificity: 84-95% 1
• Key findings in torsion:
  • Decreased or absent blood flow on color Doppler
  • "Whirlpool sign" (twisted spermatic cord) - 96% sensitivity, 99% specificity 1
  • Heterogeneous testicular echogenicity (in later stages)

Time Considerations

• Testicular salvage rates decrease dramatically with time:
  • <6 hours: >90% salvage rate
  • 6-12 hours: ~50% salvage rate

  • 24 hours: <10% salvage rate 2

• This time-dependent outcome underscores why surgical exploration should not be delayed for imaging when clinical suspicion is high

Pitfalls and Caveats

1. False negatives with Doppler: Early torsion or partial torsion may still show some blood flow on Doppler, leading to missed diagnoses
2. Operator dependency: Doppler ultrasound quality varies with technician experience
3. Availability delays: Obtaining ultrasound may introduce critical delays in treatment
4. Negative exploration rate: Studies show that immediate surgical exploration without imaging leads to higher negative exploration rates, but this is preferable to missing a case of torsion 3

Algorithmic Approach

1. High clinical suspicion:

   • Immediate surgical exploration without imaging
   • Consider manual detorsion attempt while preparing for surgery (does not eliminate need for surgery)

2. Intermediate clinical suspicion:

   • Rapid Doppler ultrasound if immediately available
   • If Doppler shows decreased/absent flow or whirlpool sign → surgical exploration
   • If Doppler is normal but clinical suspicion persists → surgical exploration

3. Low clinical suspicion:

   • Doppler ultrasound to evaluate for alternative diagnoses
   • Close follow-up if non-torsion diagnosis is made

Evidence Summary

The American College of Radiology guidelines emphasize that while Doppler ultrasound has high sensitivity and specificity, it should not delay surgical intervention when clinical suspicion is high 1. A study comparing primary scrotal exploration versus initial ultrasound examination showed that ultrasound could obviate unnecessary explorations in some cases, but this benefit must be weighed against potential treatment delays 1.

Research demonstrates that no single clinical or imaging sign is sensitive enough to definitively rule out testicular torsion, supporting a lower threshold for surgical exploration 3. Even with atypical presentations, such as back pain rather than scrotal pain, urgent surgical exploration is recommended when torsion is suspected 4.