What is the management of testicular torsion, an exception to Courvoisier's (Courvoisier's law) law?

Management of Testicular Torsion: An Exception to Courvoisier's Law

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

• Testicular torsion occurs more frequently in adolescents, with a bimodal distribution peaking in neonates and postpubertal boys 1
• Classic presentation includes sudden onset of severe scrotal pain, often accompanied by nausea and vomiting 1, 2
• A negative Prehn sign (pain not relieved when testicle is elevated) is a key distinguishing feature of testicular torsion 1
• Although severe pain is typically considered cardinal, some cases may present with minimal pain, which should not exclude the diagnosis 3

Diagnostic Evaluation

• The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can be used for risk stratification with high predictive value 1, 4
• TWIST scoring components include: testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1) 4
• For low-risk patients (score ≤2), testicular torsion is unlikely (negative predictive value 96.61%) 4
• For high-risk patients (score ≥5), testicular torsion is highly likely (positive predictive value 92.86%) 4
• Duplex Doppler ultrasound is the first-line imaging modality, with key findings including decreased or absent blood flow to the affected testicle 1
• The "whirlpool sign" of the twisted spermatic cord is the most specific ultrasound sign for testicular torsion 1

Management Algorithm

1. Immediate urological consultation for all suspected cases 1

2. For high clinical suspicion (TWIST score ≥5):

   • Proceed directly to surgical exploration without delay 1, 4
   • Manual detorsion may be attempted while preparing for surgery but must be followed by surgical confirmation 5

3. For intermediate suspicion (TWIST score 1-5):

   • Urgent Doppler ultrasound 1
   • If positive or inconclusive, proceed to surgical exploration 1

4. Surgical management:

   • Detorsion and orchiopexy of the affected testicle if viable 1, 5
   • Orchidectomy if non-viable 1
   • Prophylactic orchiopexy of the contralateral testicle to prevent future torsion 1, 5

Critical Time Considerations

• The 6-8 hour window from symptom onset is critical for testicular salvage 1, 2
• Surgical outcomes are significantly better when intervention occurs within 12 hours of symptom onset 1
• Even with delayed presentation, surgical exploration is indicated as partial testicular function may be preserved 3, 6

Common Pitfalls and Caveats

• Mistaking testicular torsion for epididymitis, especially in adolescents - epididymitis is more common in adults over 25 years 1
• Relying solely on pain severity - some cases may present without severe pain 3
• Delaying surgical intervention while waiting for imaging - in high-risk cases, proceed directly to surgery 1, 4
• False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion 1
• Failing to perform prophylactic contralateral orchiopexy, which is standard of care 1, 5
• Overlooking the possibility of bilateral torsion, which requires immediate bilateral exploration 6