What is the appropriate workup for suspected testicular torsion?

Testicular Torsion Workup

Suspected testicular torsion requires immediate urological consultation and prompt surgical exploration as the definitive approach, with imaging only when diagnosis is uncertain and won't delay treatment. 1

Clinical Presentation and Initial Assessment

• Testicular torsion typically presents with sudden onset of severe scrotal pain, often accompanied by nausea and vomiting 2, 3

• Physical examination findings suggestive of testicular torsion include:

  • Testicular swelling and tenderness 4
  • Hard testicle on palpation 4
  • Absent cremasteric reflex (most accurate clinical sign) 3
  • High-riding testicle 4
  • Negative Prehn sign (pain not relieved when testicle is elevated) 2, 5

• The TWIST (Testicular Workup for Ischemia and Suspected Torsion) scoring system can help risk-stratify patients:

  • Components: testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), high-riding testis (1) 4
  • Low risk: ≤2 points (negative predictive value 100%) 4
  • High risk: ≥5 points (positive predictive value 100%) 4
  • Intermediate risk: 3-4 points (requires further evaluation) 4

Imaging Studies

• Doppler ultrasound is the imaging modality of choice when diagnosis is uncertain 2

  • Key findings include:
    • Decreased or absent blood flow to affected testicle 2, 3
    • "Whirlpool sign" of the twisted spermatic cord (96% sensitivity, 99% specificity) 2
    • Homogeneous echo pattern suggests viable testis 2
    • Heterogeneous echo pattern suggests non-viable testis 2

• Power Doppler is more sensitive than color Doppler, especially for slow flow areas and prepubertal testes 2

• Advanced ultrasound techniques that may be helpful in equivocal cases:

  • Contrast-enhanced ultrasound can assess microvascularity 2
  • Microvascular imaging better differentiates slow flow 2
  • Shear wave elastography can evaluate tissue stiffness 2

Management Algorithm

1. High clinical suspicion (high TWIST score or classic presentation):

   • Immediate urological consultation without imaging 1
   • Surgical exploration within 6-8 hours of symptom onset is essential to prevent testicular loss 2, 3

2. Intermediate clinical suspicion:

   • Rapid Doppler ultrasound if immediately available 2
   • Consider ultrasound-assisted manual detorsion while awaiting surgery 6
     • This non-invasive maneuver can rapidly restore blood flow and relieve symptoms
     • Restoration of blood flow must be confirmed following the maneuver 3

3. Low clinical suspicion but testicular torsion not ruled out:

   • Doppler ultrasound to evaluate for alternative diagnoses 2
   • Common differential diagnoses include:
     • Epididymitis/epididymo-orchitis (most common cause in adults) 2
     • Torsion of testicular appendage (most common in prepubertal boys) 2
     • Strangulated inguinal hernia 5
     • Testicular tumor or hematoma 5

Important Considerations

• Time is critical - testicular salvage rates decrease significantly after 6 hours of torsion 2, 3
• Even with low clinical suspicion, maintain high vigilance in prepubertal and young adult males 3
• Imaging should never delay surgical consultation when clinical suspicion is high 1
• Post-treatment care should include bed rest, scrotal elevation, and analgesics until inflammation subsides 1