What is the management and treatment of testicular torsion?

Management and Treatment of 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 testicular damage. 1

Clinical Presentation and Diagnosis

• Testicular torsion presents with sudden-onset, severe unilateral testicular pain, often with a negative Prehn sign (pain not relieved by testicular elevation) 1

• More common in adolescents with a bimodal distribution (peaks in neonates and postpubertal boys) 1

• Emergency testing is indicated when pain onset is sudden and severe without evidence of urethritis or urinary tract infection 1

• Duplex Doppler ultrasound is the established first-line imaging modality with key findings including: 2

  • Decreased or absent blood flow to the affected testicle 2
  • "Whirlpool sign" of the twisted spermatic cord (most specific ultrasound sign) 2
  • Enlarged heterogeneous testis that may appear hypoechoic 2
  • Ipsilateral hydrocele and scrotal skin thickening 2

• Ultrasound sensitivity and specificity for testicular torsion ranges from 69% to 96.8% and 87% to 100%, respectively 2

• False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion 2

• The contralateral asymptomatic testicle should be used as an internal control 2

Treatment Algorithm

1. Immediate Surgical Intervention 1, 3

   • Surgical exploration and detorsion within 6-8 hours of symptom onset is critical for testicular salvage 1
   • Surgical outcomes are significantly better when performed within 12 hours of symptom onset 1

2. Surgical Approach 3, 4

   • Manual detorsion (counter-rotation of the twisted testis) 3, 5
   • Bilateral orchiopexy to prevent recurrence 3, 4
   • Ultrasound-assisted manual detorsion may be attempted as a temporizing measure before surgery to restore blood flow quickly 5

3. Intraoperative Decision Making 3, 4

   • If the testis is viable after detorsion: perform bilateral orchiopexy 3
   • If the testis is nonviable (black/blue with no bleeding after incision): perform orchiectomy of the affected testis and contralateral orchiopexy 3

4. Post-operative Care 1

   • Bed rest and scrotal elevation until inflammation subsides 1
   • Appropriate analgesia 1
   • Follow-up to assess testicular viability and function 1

Special Considerations

• Bilateral Torsion: Though rare, bilateral testicular torsion can occur and requires immediate bilateral exploration 6
• Neonatal Torsion: Often extravaginal and may be present at birth; immediate surgical intervention is still recommended 6
• Partial Torsion: May present with less severe symptoms but still requires surgical intervention 2

Pitfalls and Caveats

• Diagnostic Challenges: Testicular torsion can be confused with epididymitis, which typically has a more gradual onset of pain 1
• False Reassurance: False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion 2
• Delayed Presentation: Testicular salvage rates decrease significantly after 6-8 hours of ischemia 1
• Contralateral Risk: The anatomical abnormality predisposing to torsion is often bilateral, necessitating prophylactic fixation of the contralateral testis 4
• Post-detorsion Complications: Reperfusion injury can occur after detorsion, leading to oxidative stress and potential long-term effects on fertility 3

Long-term Outcomes

• Testicular torsion can lead to germ cell necrosis, arrested spermatogenesis, and diminished testosterone levels with potential impact on fertility 3
• Testicular atrophy rates after surgical intervention range from 9.1% to 47.5%, depending on the duration of ischemia before detorsion 4