What is the recommended treatment for testicular torsion?

Testicular Torsion Treatment

Immediate urological consultation and prompt surgical exploration with detorsion and bilateral orchidopexy 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

Immediate Action Required

• Surgical exploration is mandatory and should not be delayed for imaging if clinical suspicion is high 1
• The critical time window is 6-8 hours before permanent ischemic damage occurs, with better surgical outcomes when surgery occurs within 12 hours of symptom onset 1
• Testicular viability is directly time-dependent—each hour of delay significantly increases the risk of testicular loss 1, 2

Definitive Surgical Procedure

The standard surgical approach includes three essential components:

• Detorsion of the affected testis to restore blood flow 3, 4
• Ipsilateral orchidopexy (fixation of the affected testis) to prevent recurrence 3, 5
• Contralateral prophylactic orchidopexy to prevent torsion of the opposite testis, which is performed in approximately 58% of cases 3, 2

The surgical technique varies among surgeons, but all approaches aim to permanently fix the testis to prevent retorsion 3. No single fixation technique has proven superior, though no ipsilateral retorsion has been reported in systematic reviews of various techniques 3.

Manual Detorsion as Temporizing Measure

While awaiting surgical intervention, manual detorsion by external rotation can be attempted, but this is only a temporizing measure 2:

• Most torsions require lateral-to-medial rotation (opening a book) 6
• Blood flow restoration must be confirmed with Doppler ultrasound following any manual detorsion attempt 2
• Surgical exploration remains mandatory even after successful manual detorsion to perform bilateral orchidopexy and prevent recurrence 2

Post-Operative Care

Following surgical detorsion and orchidopexy 1:

• Bed rest until inflammation subsides
• Scrotal elevation and support
• Analgesics for pain control
• NSAIDs to reduce inflammation

Critical Clinical Pitfalls

Do not delay surgical consultation for imaging studies—if clinical suspicion is high based on sudden onset of severe scrotal pain, absent cremasteric reflex, and negative Prehn sign, proceed directly to surgical exploration 1, 2

False-negative Doppler ultrasound can occur with partial torsion (less than 450 degrees) or spontaneous detorsion, so maintain high clinical suspicion even with equivocal imaging 1

Normal urinalysis does not exclude testicular torsion—this is a key distinguishing feature from epididymitis 1

Prognosis and Long-Term Outcomes

• Testicular salvage rates approach 90-100% when surgery occurs within 6 hours 2
• Ipsilateral testicular atrophy rates range from 9.1% to 47.5% even after successful detorsion, depending on duration of ischemia 3
• Exocrine function (semen analysis) is often abnormal after unilateral torsion, even with testicular salvage 5
• No episodes of ipsilateral retorsion have been reported following proper orchidopexy 3