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 of symptom onset offers the best chance of saving the testicle. The condition occurs when the spermatic cord twists, cutting off blood supply to the testicle, and prompt recognition and surgical exploration within this time frame is essential to prevent testicular loss 1. The diagnosis of testicular torsion can be challenging due to the large differential diagnoses and overlapping clinical presentation, but a validated clinical risk scoring system, such as the Testicular Workup for Ischemia and Suspected Torsion Score, can help in identifying patients at high risk 1.
Some key points to consider in the diagnosis and management of testicular torsion include:
- The use of ultrasound (US) as the established first-line imaging modality for acute scrotal disease, which can help in diagnosing most scrotal disorders when combined with clinical history and physical examination 1.
- The importance of color Doppler US in evaluating testicular perfusion and differentiating scrotal emergencies, with a sensitivity and specificity for the detection of testicular torsion ranging from 69% to 96.8% and 87% to 100%, respectively 1.
- The presence of a twisted spermatic cord as the most specific US sign of torsion, and the "whirlpool sign" as a spiral twist of the spermatic cord that may be associated with a heterogeneously echogenic pseudomass below the point of torsion 1.
- The need for prompt surgical intervention, as delay in treatment can lead to testicular necrosis requiring orchiectomy (removal of the testicle), potentially affecting fertility and requiring testosterone replacement therapy in some cases 1.
In terms of management, surgery within 6 hours of symptom onset is crucial, and manual detorsion may be attempted by a physician while awaiting surgery, but this is temporary 1. Pain medication may be given for comfort, but analgesics are not the primary treatment. It is essential to note that testicular torsion can occur at any age, but it most commonly affects adolescents and young men 1.
Overall, the key to managing testicular torsion is prompt recognition and surgical intervention, and any delay in treatment can have significant consequences on morbidity, mortality, and quality of life.
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 clinical diagnosis, and patients typically present with severe acute unilateral scrotal pain, nausea, and vomiting 2.
- Physical examination may reveal a high-riding testicle with an absent cremasteric reflex 2.
- Ultrasound imaging can aid in diagnosis, with heterogeneous echogenicity and enlarged epididymis being indicative of testicular torsion 3.
Treatment and Management of Testicular Torsion
- Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum 2.
- Immediate surgical exploration is indicated if history and physical examination suggest torsion, and should not be postponed to perform imaging studies 2.
- Manual detorsion is a simple, safe, and effective maneuver that can be performed in the emergency department by emergency physicians 4.
- Manual detorsion can provide immediate symptom relief and allow for non-emergent orchiopexy 5.
Importance of Prompt Treatment
- Delay in treatment may be associated with decreased fertility, or may necessitate orchiectomy 2.
- There is typically a four- to eight-hour window before permanent ischemic damage occurs 2.
- Prompt detorsion is crucial to preserving testicular viability, and manual detorsion can maximize testis salvage 5.
Variability in Management
- The management of suspected testicular torsion can differ between urology and general surgical trainees 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 6.
- General surgical trainees are more likely to fix a normal testicle, contrary to best-practice 6.