What is the immediate treatment for suspected testicular torsion?

Immediate Treatment for Suspected Testicular Torsion

Suspected testicular torsion is a surgical emergency requiring immediate urological consultation and surgical exploration without delay, as testicular viability is compromised after 4-8 hours of torsion. 1

Clinical Presentation and Diagnosis

• Testicular torsion typically presents with:

  • Sudden onset of severe unilateral testicular pain
  • Nausea and vomiting
  • Red, swollen scrotum
  • High-riding testicle
  • Absent cremasteric reflex
  • Often occurs in adolescents
  • May occur with or without trauma 2, 1

• Key diagnostic distinctions from epididymitis:

Feature	Epididymitis	Testicular Torsion
Onset	Gradual	Sudden
Pain relief with elevation	Yes (Prehn sign)	No
Cremasteric reflex	Present	Absent
Testicular position	Normal	High-riding
Doppler ultrasound	Increased blood flow	Decreased/absent blood flow

Management Algorithm

1. Immediate Action: When testicular torsion is suspected based on clinical presentation, do not delay for imaging studies - proceed directly to surgical exploration 1

2. Manual Detorsion Attempt: While arranging for surgical intervention, the clinician may attempt manual detorsion by rotating the testicle outward (like opening a book) 2

   • This is a temporizing measure only
   • Surgical exploration is still required even if symptoms improve

3. Surgical Management:

   • Immediate scrotal exploration
   • Detorsion of the affected testicle
   • Assessment of testicular viability
   • Bilateral orchidopexy (fixation of both testes) to prevent recurrence 3
   • Orchiectomy if the testicle is necrotic

Critical Time Considerations

• The window for testicular salvage is typically 4-8 hours from symptom onset 1
• Delay beyond this timeframe significantly increases the risk of testicular loss
• Orchiectomy rates reach 42% in boys undergoing surgery for testicular torsion 1

Important Caveats

• Testicular torsion is primarily a clinical diagnosis - if suspected, do not delay treatment for imaging studies 1
• Trauma can precipitate testicular torsion, so torsion must be included in the differential diagnosis of direct testicular trauma 4
• Bilateral torsion, though rare, can occur and may be metachronous (occurring at different times) 5
• The contralateral testicle should always be fixed during surgery to prevent future torsion 3

Outcomes and Follow-up

• Testicular salvage rates correlate directly with time to surgical intervention
• Post-operative complications may include scrotal abscess (9.1%) and stitch abscess (4.5%) 3
• Ipsilateral testicular atrophy rates range from 9.1% to 47.5% even after successful detorsion 3
• Long-term fertility may be affected, though specific outcomes are not well documented

Remember that testicular torsion is one of the few true urological emergencies where minutes matter for organ preservation and future fertility.