From the Guidelines
Manual detorsion should be performed promptly in cases of suspected testicular torsion, as it can temporarily restore blood flow and prevent testicular ischemia and necrosis, with the goal of improving outcomes in terms of morbidity, mortality, and quality of life. When performed, manual detorsion involves rotating the affected testicle outward (laterally) to untwist the spermatic cord, typically in a "open book" direction (medial to lateral) 1. The procedure should be attempted while administering appropriate analgesia, such as intravenous morphine (0.1 mg/kg) or local anesthetic cord block. To perform manual detorsion, grasp the testicle with both hands and rotate it outward 180-360 degrees until pain subsides. Success is indicated by immediate pain relief and improved testicular position. However, manual detorsion is only a temporary measure to restore blood flow while arranging urgent surgical exploration, as most patients still require definitive surgical treatment (orchiopexy) to prevent recurrence 1.
The importance of prompt recognition and treatment of testicular torsion cannot be overstated, as the window for successful intervention is limited, with the best outcomes achieved when surgery is performed within 6 to 8 hours after symptom onset 1. Ultrasound (US) can be a valuable tool in the diagnosis of testicular torsion, with findings including an enlarged heterogeneous testis, ipsilateral hydrocele, skin thickening, and no color Doppler flow in the testis or spermatic cord 1. However, US findings can be variable, and clinical correlation is essential for accurate diagnosis.
Key points to consider in the management of suspected testicular torsion include:
- Prompt recognition and intervention are critical to prevent testicular loss and improve outcomes
- Manual detorsion can be a temporary measure to restore blood flow, but surgical exploration is often still necessary
- Ultrasound can be a useful diagnostic tool, but clinical correlation is essential
- The goal of treatment is to improve outcomes in terms of morbidity, mortality, and quality of life, by preventing testicular ischemia and necrosis, and reducing the need for orchiectomy.
From the Research
Manual Detorsion Procedure
- Manual detorsion is a simple, safe, and effective maneuver that can be performed in the emergency department (ED) by emergency physicians (EPs) 2.
- The procedure can be performed using bedside ultrasound to confirm the diagnosis of complete torsion of the testicle and successful reperfusion after manual detorsion 2.
- Manual detorsion is not a substitute for definitive surgical management and should only be used as a temporary measure for reperfusion to allow more time to organize the logistics of surgery 2, 3.
Success Rate and Outcomes
- The success rate of manual detorsion varies, with one study reporting a success rate of 26% (15/58) patients 3.
- Successful manual detorsion can permit non-emergency orchiopexy, and an algorithm for the management of testicular torsion that includes an attempt of manual detorsion prior to surgery is proposed 3.
- Gonadal loss after manual detorsion can occur, especially after unsuccessful manual detorsion, and emergency surgery may be necessary 3.
Direction and Degree of Testicular Torsion
- Testicular torsion can occur in both medial (inward) and lateral (outward) directions, with lateral rotation occurring in approximately 33% of cases 4, 5.
- The degree of testicular torsion can vary, with a median of 540 degrees of torsion noted in orchiectomy cases and a median of 360 degrees noted in salvaged testes 5.
- Manual detorsion should be guided by response and return of normal anatomy, and surgical exploration remains necessary since residual torsion still poses a risk to testicular viability 5.
Importance of Prompt Treatment
- Testicular torsion is a surgical emergency that requires prompt recognition and treatment to preserve testicular viability 6.
- Delay in treatment can result in decreased fertility or necessitate orchiectomy, and there is typically a four- to eight-hour window before permanent ischemic damage occurs 6.