What is the management and prognosis of testicular torsion in a pediatric patient?

Management and Prognosis of Testicular Torsion in a 13-Year-Old Patient

Testicular torsion is a surgical emergency requiring immediate urological consultation and surgical intervention within 6-8 hours of symptom onset to prevent testicular loss in pediatric patients. 1

Clinical Presentation and Diagnosis

• Testicular torsion occurs more frequently in adolescents, with a bimodal distribution peaking in neonates and postpubertal boys, with an estimated yearly incidence of 2.9 to 3.8 per 100,000 boys under 18 years of age. 2, 1

• Key clinical features include:

  • Sudden onset of severe scrotal pain 1
  • Red, swollen scrotum 3
  • Negative Prehn sign (pain not relieved when testicle is elevated) 1
  • Associated nausea and vomiting 3

• Diagnostic approach:

  • The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can be used for risk stratification with high positive predictive value. 2, 4
  • Duplex Doppler ultrasound is the first-line imaging modality with 69-96.8% sensitivity and 87-100% specificity. 1
  • Key ultrasound findings include:
    • Decreased or absent blood flow to affected testicle 1
    • "Whirlpool sign" of the twisted spermatic cord (96% sensitivity) 1
    • Enlarged heterogeneous testis, ipsilateral hydrocele, and scrotal skin thickening 1

Management Algorithm

1. Immediate Urological Consultation

   • Do not delay for imaging if clinical suspicion is high 1
   • Consider manual detorsion attempt while awaiting surgical intervention 3

2. Surgical Exploration and Detorsion

   • Critical time window of 6-8 hours before permanent ischemic damage occurs 2, 1
   • Better outcomes when surgery occurs within 12 hours of symptom onset 1, 3
   • Surgical approach includes:
     • Detorsion of the affected testicle 1
     • Assessment of testicular viability 1
     • Orchiopexy (fixation) of both testes to prevent recurrence 1

3. Post-Operative Care

   • Bed rest 1
   • Scrotal elevation 1
   • Analgesics until inflammation subsides 1

Prognosis

• Testicular salvage rates are time-dependent: 4

  • Nearly 100% if surgery within 6 hours of symptom onset 1
  • 70% if surgery within 6-12 hours 1
  • Less than 20% if surgery after 12 hours 1

• Long-term outcomes:

  • Risk of testicular atrophy increases with delayed intervention 3
  • Potential impact on fertility, especially with bilateral torsion or delayed treatment 5
  • Contralateral testicular function may be affected due to autoimmune response 5

Important Considerations and Pitfalls

• Testicular torsion can occasionally present without severe pain, which may lead to delayed diagnosis and treatment. 6

• False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion, highlighting the importance of careful interpretation of ultrasound results. 1

• Differential diagnosis to consider:

  • Epididymitis/epididymo-orchitis (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, or testicular tumor 3

• Implementation of standardized protocols with parallel notification of essential services can significantly reduce door-to-incision time and improve outcomes. 4