What is the management for chronic testicular torsion?

Management of Chronic Testicular Torsion

Chronic testicular torsion requires urgent surgical exploration with bilateral orchiopexy, as this condition represents intermittent torsion-detorsion episodes that can progress to complete torsion and testicular loss at any time. 1

Understanding Chronic (Intermittent) Testicular Torsion

Chronic testicular torsion is characterized by recurrent episodes of testicular pain due to intermittent twisting and spontaneous untwisting of the spermatic cord. 1 This condition occurs in patients with the "bell-clapper" deformity, an anatomic abnormality present in 82% of patients with intermittent torsion. 1, 2 Up to one-half of patients with acute testicular torsion report previous similar episodes, indicating prior intermittent torsion events. 2

Diagnostic Approach

Clinical Presentation

• Wave-like or recurrent pain pattern with episodes of acute scrotal pain that spontaneously resolve 1
• Pain may be severe during episodes but improves between attacks 1
• Negative Prehn sign during acute episodes (pain not relieved with testicular elevation) 1
• History of multiple similar episodes is highly suggestive 2

Imaging Evaluation

• Duplex Doppler ultrasound is the first-line imaging study, though it may appear normal between episodes when the testis has spontaneously detorsed 1
• During symptomatic episodes, look for decreased testicular blood flow, the "whirlpool sign" of twisted spermatic cord, and heterogeneous testicular echotexture 1
• Critical pitfall: Normal Doppler ultrasound does NOT exclude intermittent torsion, as false-negative evaluations occur in 30% or more of cases, particularly with spontaneous detorsion 1
• MRI can identify the underlying "bell-clapper" deformity with 83% sensitivity by demonstrating the "split sign" (hyperintense T2 signal between the posterior epididymis and scrotal wall) 1

Definitive Management: Surgical Intervention

Indications for Surgery

Any patient with recurrent testicular pain suspicious for intermittent torsion should undergo elective bilateral orchiopexy, as the risk of progression to complete torsion with testicular loss is substantial. 1, 2 Do not wait for an acute complete torsion event to occur.

Surgical Technique

• Bilateral orchiopexy is mandatory to prevent both ipsilateral recurrent torsion and contralateral torsion (which occurs due to the bilateral nature of the bell-clapper deformity) 1, 3
• Surgical exploration should include assessment of testicular viability, detorsion if currently torsed, and fixation of both testes 1, 3
• Multiple fixation techniques exist (direct suturing, eversion orchiopexy), though no single technique has proven superiority 3, 4
• Eversion orchiopexy (Jaboulay or Kocher technique) has shown no recurrence in long-term follow-up studies and may be considered a safe, effective option 4

Timing of Surgery

• Elective bilateral orchiopexy should be performed promptly once the diagnosis of intermittent torsion is established 1
• If the patient presents during an acute episode, treat as acute testicular torsion with emergency exploration within 6-8 hours 1
• The contralateral testis should be fixed during the same procedure in 100% of cases to prevent future contralateral torsion 1, 3

Critical Clinical Pitfalls

• Never adopt a "wait and see" approach with suspected intermittent torsion—the next episode may result in complete torsion and testicular loss 1, 5
• Do not be falsely reassured by normal imaging between episodes; clinical history of recurrent testicular pain is sufficient to warrant surgical intervention 1
• Always fix the contralateral testis during surgery, as the bell-clapper deformity is bilateral in the vast majority of cases 1, 2
• Postoperative complications are minimal, with scrotal or stitch abscess occurring in less than 10% of cases 3

Long-Term Considerations

• Even after successful orchiopexy, testicular atrophy rates range from 9.1% to 47.5% in some series, likely related to prior ischemic injury from intermittent torsion episodes 3
• Exocrine testicular function may be abnormal after torsion, emphasizing the importance of early intervention before significant ischemic damage accumulates 2
• No episodes of ipsilateral retorsion have been reported in studies following appropriate orchiopexy 3, 4