What is the recommended treatment for testicular torsion?

Treatment Guidelines for Testicular Torsion

Testicular torsion requires immediate urological consultation and prompt surgical exploration as the definitive treatment, with surgical intervention ideally occurring within 6-8 hours of symptom onset to prevent permanent ischemic damage. 1

Diagnosis

• Testicular torsion should be suspected in all cases of acute scrotal pain, especially when onset is sudden and severe, without evidence of urethritis or urinary tract infection 2, 1
• Ultrasound with duplex Doppler is the first-line imaging modality for diagnosis, with key findings including:
  • Decreased or absent blood flow to the affected testicle 2
  • The "whirlpool sign" of the twisted spermatic cord, which is the most specific ultrasound sign of torsion 2, 1
• The sensitivity of color Doppler ultrasound for detecting testicular torsion ranges from 69% to 96.8%, with specificity between 87% and 100% 2
• Clinical findings suggestive of torsion include:
  • Negative Prehn sign (pain not relieved when testicle is elevated) 1
  • Ipsilateral absent cremasteric reflex 3
  • High-riding, tender, swollen, and firm testicle 4

Treatment Algorithm

1. Immediate Urological Consultation

   • Testicular torsion is a surgical emergency requiring prompt specialist evaluation 1, 4

2. Consider Manual Detorsion

   • While awaiting surgical intervention, ultrasound-assisted manual detorsion may be attempted to restore blood flow 5
   • This involves external rotation of the testicle (typically in an outward direction) 3
   • Blood flow must be confirmed after the maneuver, typically with Doppler ultrasound 3
   • Note: Manual detorsion is not a substitute for definitive surgical management 3

3. Surgical Management

   • Surgical exploration is the definitive treatment for testicular torsion 1, 3
   • The procedure involves:
     • Detorsion of the affected testicle
     • Orchiopexy (fixation) of the affected testicle if viable
     • Prophylactic orchiopexy of the contralateral testicle to prevent future torsion 3
   • Orchiectomy may be necessary if the testicle is not viable 4

4. Post-Treatment Care

   • Bed rest and scrotal elevation until inflammation subsides 2, 1
   • Appropriate analgesics for pain management 1

Critical Time Considerations

• The viability of the testicle is time-dependent, with the critical window being 6-8 hours from symptom onset 1
• Surgical outcomes are significantly better when surgery occurs within 12 hours of symptom onset 1
• Delayed intervention beyond this timeframe significantly increases the risk of testicular loss 3

Special Considerations

• Bilateral torsion, though rare, has been reported and requires immediate bilateral surgical intervention 6
• In neonatal and pediatric cases, even when testicular salvage is not possible, preservation of the affected testis may be considered as some endocrine function may be retained 6
• Anatomic defects, particularly the "bell-clapper" deformity, are often present in patients with testicular torsion and predispose to this condition 4

Potential Complications

• Testicular loss if treatment is delayed beyond the critical time window 1, 3
• Impaired exocrine function (abnormal semen analysis) has been reported even after successful treatment of unilateral torsion 4
• Recurrence in the contralateral testicle if prophylactic orchiopexy is not performed 3