What happens if no surgical treatment is done for a non-viable testis after torsion?

What Happens if a Non-Viable Testis After Torsion is Left Untreated

If a non-viable testis after torsion is not surgically removed, it will undergo complete necrosis and can lead to serious complications including infection, abscess formation, sepsis, chronic pain, and potential autoimmune reactions against the contralateral testis. 1

Immediate Surgical Management is Standard of Care

The established medical practice dictates immediate orchiectomy for a non-viable testis following testicular torsion. 1, 2 This recommendation exists because:

• Necrotic tissue poses infection risk: A necrotic testis serves as a nidus for bacterial infection, potentially progressing to scrotal abscess, Fournier's gangrene, or systemic sepsis 1
• Autoimmune concerns: Breakdown of the blood-testis barrier in necrotic tissue may expose sperm antigens, theoretically risking autoimmune orchitis in the contralateral testis, though this remains controversial 1
• Chronic pain and inflammation: Dead testicular tissue causes persistent inflammatory response with ongoing scrotal pain and swelling 1, 2

Critical Caveat: Viability Assessment is Imperfect

Recent evidence reveals a significant problem with current surgical decision-making:

• 10% of removed testes were potentially salvageable: Retrospective histological review using the Mikuz grading system found that 10.4% of orchiectomy specimens showed only "grade 1" (reversible) injury, and an additional 35.4% showed "grade 2" injury of uncertain reversibility 3
• Surgeon assessment is subjective: The decision to remove versus salvage a testis relies entirely on the surgeon's visual assessment of macroscopic appearance, which lacks objective criteria and can be inaccurate 3
• Time is not absolute: Three of five patients with grade 1 (reversible) injury had symptoms exceeding 12 hours, with one exceeding 24 hours, challenging the traditional time-based viability assumptions 3

Ultrasound Findings Can Predict Viability

Heterogeneous parenchymal echo texture on ultrasound universally predicts testicular non-viability (100% specificity), while homogeneous isoechoic texture predicts viability in 89% of cases. 4

• In a study of 55 boys with absent Doppler flow, all 37 testes (100%) with heterogeneous echo texture were non-viable at exploration, with pathology confirming necrosis in all cases 4
• Conversely, 16 of 18 testes (89%) with homogeneous echo texture were viable and successfully salvaged 4
• This finding suggests that heterogeneous testes may not require emergent exploration if surgical resources are limited, though this remains controversial 4

Practical Clinical Algorithm

When encountering suspected non-viable testis after torsion:

1. Perform immediate surgical exploration within 6-8 hours of symptom onset when possible 1, 2
2. Assess parenchymal echo texture on ultrasound if imaging is performed - heterogeneity strongly suggests non-viability 4
3. At exploration, visually assess the testis after detorsion for color, turgor, and bleeding from tunica albuginea incision 1
4. Consider orchiopexy even for questionable viability given that 10% of "non-viable appearing" testes may be salvageable 3
5. Always perform contralateral orchiopexy to prevent future torsion, as the bell-clapper deformity is bilateral in 82% of cases 1

Consequences of Non-Treatment

If surgical intervention is completely avoided and a necrotic testis remains in situ:

• Infection and abscess formation become increasingly likely as necrotic tissue breaks down 1, 2
• Systemic sepsis can develop from untreated scrotal infection 1
• Chronic scrotal pain and swelling persist indefinitely 1, 2
• Testicular atrophy occurs with eventual calcification of the necrotic tissue 3
• Potential fertility implications from autoimmune response remain theoretical but concerning 1

The standard of care remains immediate surgical exploration and orchiectomy for clearly non-viable testes, though emerging evidence suggests we may be removing some potentially salvageable organs due to limitations in intraoperative viability assessment. 3