What is the management of testicular torsion, specifically extravaginal vs intravaginal testicular torsion?

Management of Extravaginal vs Intravaginal Testicular Torsion

Testicular torsion is a surgical emergency requiring immediate urological consultation and prompt surgical exploration within 6-8 hours of symptom onset to prevent permanent ischemic damage, regardless of whether it is extravaginal or intravaginal. 1

Types of Testicular Torsion

• Extravaginal Torsion:

  • Occurs primarily in neonates and infants within the first month of life 2
  • Involves rotation of the testis and tunica vaginalis as a unit due to lack of fixation of the tunica to the scrotal wall 2
  • Typically presents as a hardened, enlarged testicle with scrotal discoloration 2
  • Often occurs prenatally or perinatally 2

• Intravaginal Torsion:

  • More common in adolescents, especially during puberty 1, 3
  • Associated with the "bell-clapper deformity" (abnormal tunica vaginalis attachment) 4
  • Presents with sudden onset of severe scrotal pain, often with nausea and vomiting 3
  • Typically occurs spontaneously or after minor trauma 3

Diagnostic Approach

• Clinical Assessment:

  • Evaluate for sudden onset of severe testicular pain (key feature of torsion) 1
  • Look for negative Prehn sign (pain not relieved when testicle is elevated) 1
  • Check for absent cremasteric reflex and positive Deming's sign 5
  • Note the bimodal age distribution: neonates and postpubertal boys 1, 4

• Imaging:

  • Duplex Doppler ultrasound is the first-line imaging modality with 96-100% sensitivity 1
  • Key findings include:
    • Decreased or absent blood flow to affected testicle 1, 4
    • "Whirlpool sign" of the twisted spermatic cord (96% sensitivity) 1
    • Enlarged heterogeneous or hypoechoic testis 4, 2
  • Ultrasound elastography may be useful for assessing hardening of necrotic testicle 2

Management Algorithm

1. Immediate Urological Consultation for any suspected testicular torsion 1, 4

2. Time-Critical Intervention:

   • Critical window of 6-8 hours before permanent ischemic damage 1, 4
   • Better surgical outcomes when performed within 12 hours of symptom onset 1

3. Surgical Management:

   • For Extravaginal Torsion (Neonates):

     • Immediate surgical exploration 6
     • Orchiectomy if testicle is clearly nonviable 2
     • Consider preserving affected testes when possible as some endocrine function may be retained 6
     • Contralateral orchiopexy is recommended due to risk of metachronous torsion 6

   • For Intravaginal Torsion (Adolescents/Adults):

     • Immediate surgical detorsion and orchiopexy if viable 1, 3
     • Orchiectomy if testicle is nonviable 3, 7
     • Contralateral orchiopexy to prevent future torsion 7

4. Post-operative Care:

   • Bed rest, scrotal elevation, and analgesics until inflammation subsides 1

Common Pitfalls and Caveats

• Diagnostic Challenges:

  • Extravaginal torsion can be confused with other causes of acute scrotum in neonates 2
  • Rare cases of extravaginal torsion can occur in pubertal boys, leading to diagnostic delay 5
  • Physical examination and imaging can be inaccurate in cases of perinatal torsion 6

• Management Considerations:

  • Never delay surgical exploration when torsion is suspected, even if imaging is inconclusive 1, 7
  • Bilateral torsion is being more frequently reported and may be missed if not specifically evaluated 6
  • In neonatal torsion, immediate surgical intervention is recommended even when bilateral torsion is suspected 6

• Differential Diagnosis:

  • Epididymitis (most common cause of testicular pain in adults) 1
  • Torsion of testicular appendage (most common cause in prepubertal boys) 1
  • Strangulated inguinal hernia, traumatic hematoma, testicular tumor 3