Should patients with testicular torsion be kept Nil Per Os (NPO)?

From the Guidelines

Patients with testicular torsion should generally be kept NPO (nothing by mouth) until surgical intervention can be performed. Testicular torsion is a urological emergency requiring prompt surgical exploration and detorsion, typically within 4-6 hours of symptom onset to maximize testicular salvage rates, as highlighted in the 2024 update of the ACR Appropriateness Criteria for acute onset of scrotal pain without trauma or antecedent mass 1. Keeping patients NPO is necessary because surgical intervention under anesthesia is the standard treatment, and having food or liquids in the stomach increases the risk of aspiration during general anesthesia.

While preparing for surgery, pain management can be achieved with intravenous analgesics. The importance of not delaying management of emergencies such as ischemic testicular torsion is also emphasized in a systematic review on guidelines and recommendations for urology standard of care during the COVID-19 pandemic 1. If surgery is delayed or manual detorsion is attempted, the patient should still remain NPO until surgical management is definitively planned or ruled out. The NPO status is a standard precaution for any condition that may require emergency surgery, as testicular torsion has a limited window for intervention before permanent ischemic damage occurs to the testicle.

Key considerations in managing testicular torsion include:

• Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset to prevent testicular loss 1
• Use of a validated clinical risk scoring system, such as the Testicular Workup for Ischemia and Suspected Torsion Score, to aid in diagnosis 1
• The potential for testicular torsion to occur at any age, with a bimodal distribution presenting more frequently in neonates and postpubertal boys than in adults 1

From the Research

Testicular Torsion Management

• The provided studies do not directly address whether patients with testicular torsion should be kept NPO (nil per os, or nothing by mouth) 2, 3, 4, 5, 6.
• However, it is known that testicular torsion is a surgical emergency that requires prompt treatment to prevent complications such as testicular infarction, necrosis, and sub/infertility 2, 3.
• The management of testicular torsion typically involves immediate surgical exploration, and delay in treatment may be associated with decreased fertility or necessitate orchiectomy 2, 4.
• There is no mention of the need for patients to be kept NPO in the provided studies, suggesting that this may not be a critical aspect of testicular torsion management.

Surgical Intervention

• Surgical intervention is crucial in the management of testicular torsion, and immediate detorsion has been shown to lead to improved surgical outcomes 4.
• The study by 4 found that transfer time was inversely associated with testicular salvage, and each hour of surgical wait time decreased surgical salvage by 6%.
• Another study highlighted the importance of prompt diagnosis and treatment to prevent complications and improve outcomes 3.

Testicular Function

• Testicular torsion can have long-term effects on testicular function, including decreased sperm motility and reduced sperm counts 6.
• However, the impact of testicular torsion on endocrine function is less clear, with most studies finding no significant alterations in hormone levels 6.