What is the treatment for testicular torsion?

Treatment of Testicular Torsion

Immediate urological consultation and prompt surgical exploration (detorsion with bilateral orchiopexy) is the definitive treatment for testicular torsion, and must be performed within 6-8 hours of symptom onset to prevent permanent testicular loss. 1

Surgical Management Algorithm

Timing is Critical

• Surgical intervention must occur within 6-8 hours of symptom onset to prevent permanent ischemic damage and preserve testicular viability. 1
• Surgical outcomes are significantly better when surgery occurs within 12 hours of symptom onset, though the 6-8 hour window is the critical threshold. 1
• The degree of ischemic injury is directly determined by the severity of arterial compression and the time interval between symptom onset and surgical intervention. 2

Surgical Procedure Components

• Surgical exploration with detorsion of the affected testis is the primary intervention, which involves untwisting the spermatic cord to restore blood flow. 1, 3
• Bilateral orchiopexy must be performed - the affected testis is fixed to prevent recurrence, and prophylactic fixation of the contralateral testis is mandatory since the anatomic predisposition (bell-clapper deformity) is typically bilateral. 3, 2
• Even in cases where the testis appears non-viable, preservation should be attempted when possible as some endocrine function may be retained. 4

Pre-Surgical Considerations

Manual Detorsion

• Manual detorsion by external rotation of the testis can be attempted while awaiting surgical intervention, but this is only a temporizing measure. 3
• Restoration of blood flow must be confirmed following any manual detorsion attempt using Doppler ultrasound, and surgical exploration with bilateral orchiopexy is still required even if manual detorsion is successful. 3
• Manual reduction should never delay definitive surgical treatment. 5

Immediate Consultation

• Do not wait for imaging confirmation if clinical suspicion is high - immediate urological consultation should be obtained for any suspected testicular torsion. 1
• Emergency testing and surgical referral are indicated when pain onset is sudden, pain is severe, and there is no evidence supporting urethritis or urinary tract infection. 1

Post-Operative Care

• Bed rest, scrotal elevation, and analgesics should be provided until inflammation subsides following surgical intervention. 1
• Patients should be counseled that exocrine function (semen analysis) is often abnormal after unilateral torsion, even with successful surgical treatment. 2

Special Populations

Neonatal/Perinatal Torsion

• Immediate surgical intervention is recommended for both unilateral and bilateral neonatal testicular torsion, as physical examination and imaging can be inaccurate in assessing the contralateral testis. 4
• Bilateral perinatal torsion is being reported more frequently than previously recognized, and metachronous contralateral torsion can occur. 4

Common Pitfalls to Avoid

• Never adopt a "watchful waiting" approach - testicular torsion is a true surgical emergency requiring immediate intervention. 6, 5
• Do not be falsely reassured by partial improvement in symptoms, as partial torsion or spontaneous detorsion can still result in testicular loss and requires surgical exploration. 1
• Do not delay surgery to obtain imaging if clinical suspicion is high based on history and physical examination findings (absent cremasteric reflex, high-riding testis, negative Prehn sign). 1, 3