What is the next step when suspecting testicular torsion, is it an ultrasound?

Immediate Urological Consultation and Surgical Exploration is the Next Step

When testicular torsion is suspected with high clinical probability, proceed directly to immediate urological consultation and surgical exploration without waiting for imaging, as testicular viability depends on intervention within 6-8 hours of symptom onset. 1

Risk Stratification Determines the Role of Ultrasound

The decision to obtain ultrasound versus proceeding directly to surgery depends on your clinical suspicion level:

High Clinical Suspicion (TWIST Score ≥5)

• Proceed directly to surgical exploration without ultrasound 1
• Key high-risk features include: testicular swelling (2 points), hard testicle (2 points), absent cremasteric reflex (1 point), nausea/vomiting (1 point), and high-riding testis (1 point) 2
• Delaying surgery for imaging in high-probability cases compromises testicular salvage 1

Intermediate Clinical Suspicion (TWIST Score 1-5)

• Urgent Duplex Doppler ultrasound is indicated 1
• This is the only scenario where ultrasound should be obtained 1
• Ultrasound should include grayscale examination, color Doppler assessment of testicular perfusion, and power Doppler 1
• The "whirlpool sign" of twisted spermatic cord has 96% sensitivity 1, 3
• Color Doppler showing decreased or absent blood flow has 96-100% sensitivity 1

Low Clinical Suspicion (TWIST Score 0-1)

• Testicular torsion is effectively ruled out with 100% negative predictive value 2
• Consider alternative diagnoses such as epididymitis or torsion of testicular appendage 1

Critical Time-Dependent Considerations

The 6-8 hour window from symptom onset is the critical threshold for testicular salvage 1, 3:

• Surgical outcomes are significantly better when intervention occurs within 12 hours 1
• Complete torsion >450 degrees results in absent arterial and venous flow 1
• Permanent ischemic damage occurs after 6-8 hours 1

Important Clinical Pitfalls to Avoid

Don't Rely on Pain Relief Alone

• Up to one-third of patients show residual torsion even after manual detorsion provides pain relief 4
• If attempting bedside manual detorsion, use color Doppler ultrasound guidance to confirm complete restoration of blood flow 4

Don't Be Falsely Reassured by Normal Urinalysis

• Normal urinalysis does not exclude testicular torsion 1
• Testicular torsion typically presents with abrupt onset of severe pain and normal urinalysis, unlike epididymitis which has gradual onset 1

Don't Miss Partial Torsion

• Partial torsion may present with less severe symptoms but still requires surgical intervention 1
• False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion 1
• Partial torsion shows diminished arterial velocity and decreased diastolic flow 1

Age-Specific Considerations

• Adolescents and postpubertal boys: Testicular torsion is most common in this population with bimodal peaks in neonates and postpubertal boys 1, 3
• Neonates: Immediate surgical intervention is recommended for perinatal torsion occurring after birth 3
• Adults over 35 years: Testicular torsion is rare; epididymitis becomes the overwhelmingly most common cause of testicular pain 1

The Bottom Line Algorithm

1. Calculate clinical suspicion using TWIST score or clinical gestalt 2
2. High suspicion → Direct to OR without imaging 1
3. Intermediate suspicion → Urgent Doppler ultrasound 1
4. Low suspicion → Consider alternative diagnoses 1
5. All surgical cases → Bilateral orchiopexy to prevent contralateral torsion 1