From the Guidelines
Testicular torsion is a medical emergency that requires immediate surgical intervention, and if suspected, one should go to the emergency room immediately as surgery within 6 hours offers the best chance of saving the testicle. The condition occurs when the spermatic cord twists, cutting off blood supply to the testicle, leading to tissue death and potentially resulting in infertility or testicle loss 1. According to the American College of Radiology, ultrasound (US) is the established first-line imaging modality for acute scrotal disease and can be used to diagnose most scrotal disorders when combined with clinical history and physical examination 1.
Key Points to Consider
- Testicular torsion has a bimodal distribution, presenting more frequently in neonates and postpubertal boys than in adults, although it can occur at any age 1.
- Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss 1.
- Ultrasound findings in testicular torsion include an enlarged heterogeneous testis, ipsilateral hydrocele, skin thickening, and no color Doppler flow in the testis or spermatic cord 1.
- A twisted spermatic cord is the most specific US sign of torsion, and the "whirlpool sign" refers to a spiral twist of the spermatic cord that may be associated with a heterogeneously echogenic pseudomass below the point of torsion 1.
Management and Treatment
- While awaiting medical care, pain can be managed with NSAIDs like ibuprofen (400-600mg orally) or acetaminophen (1000mg orally) 1.
- During surgery (orchiopexy), the surgeon will untwist the cord, evaluate testicle viability, and secure both testicles to prevent future torsion 1.
- Recovery typically requires 1-2 weeks of rest with scrotal support, ice packs for the first 48 hours, and avoiding strenuous activity for 4-6 weeks 1.
- Any delay in treatment significantly reduces the chance of saving the affected testicle, with success rates dropping from 90% when treated within 6 hours to less than 10% after 24 hours 1.
From the Research
Definition and Diagnosis of Testicular Torsion
- Testicular torsion is a twisting of the spermatic cord and its contents, affecting 3.8 per 100,000 males younger than 18 years annually 2.
- It is a surgical emergency that requires prompt recognition and treatment for testicular salvage 2, 3.
- Patients typically present with severe acute unilateral scrotal pain, nausea, and vomiting, and physical examination may reveal a high-riding testicle with an absent cremasteric reflex 2.
Treatment and Management of Testicular Torsion
- Immediate surgical exploration is indicated if history and physical examination suggest torsion, and should not be postponed to perform imaging studies 2.
- There is typically a four- to eight-hour window before permanent ischemic damage occurs, and delay in treatment may be associated with decreased fertility or necessitate orchiectomy 2.
- Manual detorsion is a simple, safe, and effective maneuver that can be performed in the emergency department by emergency physicians, and can rapidly restore testicular blood flow and maximize testicular salvage 3, 4, 5.
Role of Ultrasound in Testicular Torsion
- Ultrasound can help in the rapid diagnosis of complete testicular torsion and assessment of alternative causes of acute scrotal pain 4.
- Bedside ultrasound performed by a trained emergency physician can significantly reduce the time to diagnosis and reperfusion by means of performing an ultrasound-guided manual detorsion in the emergency department 4.
- Ultrasound-assisted manual testicular detorsion is a non-invasive, simple, quick, safe, and effective maneuver that can rapidly restore testicular blood flow and maximize testicular salvage 3.
Surgical Management and Training
- Scrotal exploration is a surgical emergency that requires urgent attention, and provision of urology on-call cover varies widely between hospitals 6.
- Urology trainees are more likely to be taught scrotal exploration by urologists, and are more aware of evidence regarding chronic pain and infertility following testicular fixation than surgical trainees 6.
- Surgical trainees are more likely to fix a normal testicle than urology trainees, which may be due to the different sources of training received by the two groups 6.