Manual Detorsion Technique in Testicular Torsion
Manual detorsion should be performed by rotating the affected testicle outward (lateral rotation) in a "book opening" fashion—typically 180-360 degrees or more—with immediate pain relief and restoration of blood flow on color Doppler ultrasound serving as endpoints for successful detorsion. 1, 2
Procedural Technique
Direction of Rotation
- Rotate the testicle from medial to lateral (outward), like opening a book, as most torsions occur in a medial (inward) direction 3, 4
- The right testicle should be rotated counterclockwise when viewed from below 3
- The left testicle should be rotated clockwise when viewed from below 3
- Be aware that 10-30% of torsions occur in the opposite (lateral/outward) direction, so if the initial rotation increases pain, immediately reverse direction 4
Degree of Rotation
- Perform at least one complete 360-degree rotation, and be prepared to rotate up to 540-720 degrees (1.5-2 full turns), as the spermatic cord can twist multiple times 1, 3
- Pain relief after 360 degrees does not guarantee complete detorsion—residual torsion was found in up to 27.5% of cases at surgery despite initial pain improvement 3
Endpoints for Success
- Complete resolution of pain is necessary but not sufficient to confirm successful detorsion 1, 3
- Color Doppler ultrasound confirmation of restored blood flow is essential to verify complete detorsion 1, 2, 5
- In one case report, a patient had pain relief after 360-degree rotation, but Doppler showed incomplete flow restoration; an additional 180-degree turn was required to achieve complete reperfusion 1
Ultrasound-Guided Approach
Real-Time Guidance Benefits
- Use color Doppler ultrasound during the procedure to visualize the direction of rotation and confirm restoration of testicular blood flow 1, 2, 5
- Real-time ultrasound guidance ensures detorsion in the proper direction and to completion, preventing incomplete detorsion 1, 5
- The "whirlpool sign" (twisted spermatic cord) can help identify the direction of torsion before attempting detorsion 6, 5
Post-Detorsion Confirmation
- Immediately perform color Doppler assessment after each rotation attempt to document return of arterial flow 1, 2
- Compare blood flow to the contralateral testicle as an internal control 7, 6
- Power Doppler may be more sensitive for detecting low-flow states 7
Critical Considerations
Timing and Urgency
- Manual detorsion should be attempted immediately upon diagnosis, as testicular viability is compromised after 6-8 hours of ischemia 6, 8
- This procedure maximizes testis salvage by providing immediate reperfusion while awaiting definitive surgical management 2, 3
- Manual detorsion is not a substitute for surgery—all patients require subsequent orchiopexy, which can be performed semi-electively after successful detorsion rather than emergently 2, 3
Success Rates and Pitfalls
- Manual detorsion success rates range from 26% to complete success in reported series 3
- Common reasons for failure include: patient discomfort, incomplete rotation, rotation in the wrong direction, and severe edema preventing manipulation 3, 4, 5
- Even with successful manual detorsion and pain relief, 27.5% of patients had residual cord torsion found at surgery, emphasizing the need for ultrasound confirmation 3
Pain Management
- Adequate analgesia and/or procedural sedation may be necessary to allow complete detorsion, as the procedure can be quite painful 3
- Pain relief during the procedure suggests correct direction of rotation 1, 3
- Increased pain indicates rotation in the wrong direction and requires immediate reversal 4
Post-Detorsion Management
- All patients require surgical exploration and bilateral orchiopexy, even after successful manual detorsion 2, 3
- Successful manual detorsion allows for semi-elective rather than emergency surgery, which can be critical in remote settings 2
- The testicular salvage rate depends on the degree of torsion (180-720 degrees) and duration of ischemia 7, 6