What are the signs and treatment of testicular torsion?

Signs and Treatment of Testicular Torsion

Testicular torsion is a surgical emergency that requires immediate specialist consultation because testicular viability may be compromised if not treated promptly within 6-8 hours of symptom onset. 1, 2

Clinical Presentation

Key Signs and Symptoms

• Sudden onset of severe unilateral testicular pain 1, 3
• Nausea and vomiting 4, 2
• Red, swollen scrotum 4
• High-riding testicle 3, 5
• Absent cremasteric reflex (94.9% of cases) 3, 6
• Negative Prehn sign (pain not relieved when testicle is elevated) 3, 1

Distinguishing Features from Other Conditions

• More common in adolescents but can occur at any age 1, 5
• More frequent in patients without evidence of inflammation or infection 1
• Occurs more frequently among adolescents than adults 1
• Bimodal distribution with peaks in neonates and postpubertal boys 1

Diagnostic Evaluation

Emergency Assessment

• Testicular torsion is primarily a clinical diagnosis requiring immediate action 2
• If clinical suspicion is high, immediate surgical exploration is indicated without waiting for imaging 2
• Emergency testing for torsion is indicated when:
  • Onset of pain is sudden 1
  • Pain is severe 1
  • Test results do not support diagnosis of urethritis or urinary tract infection 1

Imaging

• Doppler ultrasound is the most helpful imaging modality to confirm diagnosis 4, 1
• Key ultrasound findings:
  • Decreased or absent blood flow to affected testicle 3, 6
  • "Whirlpool sign" of the twisted spermatic cord (96% sensitivity, 99% specificity) 1
  • Heterogeneous echogenicity in non-viable testes 6

Treatment

Immediate Management

• Immediate urological consultation is essential 1
• Manual detorsion may be attempted while awaiting surgical intervention 3
• Ultrasound-guided detorsion can improve success rates of manual reduction 3

Surgical Management

• Prompt surgical exploration is the definitive treatment 2, 5
• Critical time window of 6-8 hours before permanent ischemic damage occurs 1, 2
• Surgical outcomes:
  • Testicular salvage is possible if surgery occurs within 12 hours of symptom onset 6
  • Median duration of symptoms was 12 hours in cases where testes were preserved versus 90 hours when removed 6
  • Bilateral orchiopexy is performed to prevent recurrence 5

Post-Treatment Care

• Bed rest, scrotal elevation, and analgesics until inflammation subsides 1
• Long-term hormonal levels typically remain within normal range regardless of testicular outcome 6
• Follow-up is needed to assess fertility after testicular torsion 6

Common Pitfalls and Caveats

• Mistaking testicular torsion for epididymitis can lead to critical delays in treatment 1
• Relying solely on imaging when clinical suspicion is high may delay necessary surgical intervention 2
• Previous similar episodes may be reported in up to half of patients, suggesting intermittent torsion 5
• An anatomic defect known as "bell-clapper deformity" is usually present in cases of testicular torsion 5