Testicular Torsion Treatment
Testicular torsion requires immediate urological consultation and urgent surgical exploration within 6-8 hours of symptom onset—imaging should never delay surgery when clinical suspicion is high. 1
Immediate Management Algorithm
When to Proceed Directly to Surgery (No Imaging)
- High clinical suspicion cases (TWIST score 6-7, absent cremasteric reflex, sudden severe pain with high-riding tender testis) should proceed immediately to surgical exploration without any imaging delays 1, 2
- The critical time window is 6-8 hours from symptom onset before permanent ischemic damage occurs, with testicular salvage rates declining significantly after this period 1, 3
When Imaging is Appropriate
- Intermediate clinical suspicion (TWIST score 1-5) warrants urgent Duplex Doppler ultrasound of the scrotum, but this should not delay surgery if clinical concern remains high 1, 2
- Ultrasound findings confirming torsion include decreased/absent blood flow, "whirlpool sign" of twisted spermatic cord, and enlarged heterogeneous hypoechoic testis 1, 2
Definitive Surgical Treatment
Surgical Procedure Components
- Inguinal or scrotal exploration with immediate detorsion of the affected testis 1
- Assessment of testicular viability after detorsion to determine if orchiectomy is necessary 1
- Bilateral orchiopexy is mandatory—even if one testis is removed—because 82% of patients have the "bell-clapper" deformity bilaterally, placing the contralateral testis at risk 1, 4
Surgical Outcomes by Timing
- Surgery within 6 hours: highest salvage rates 1, 5
- Surgery within 12 hours: improved outcomes compared to delayed intervention 1
- Beyond 12 hours: significantly increased orchiectomy rate (42% overall in surgical series) 3
Post-Operative Care
- Bed rest, scrotal elevation, and analgesics until inflammation subsides 1
- Long-term monitoring for testicular atrophy and fertility concerns, as exocrine function is often abnormal after unilateral torsion 4
Critical Clinical Pitfalls
False-Negative Ultrasound Risk
- Doppler ultrasound has 30% false-negative rate, particularly with partial torsion (<450 degrees), spontaneous detorsion, or early presentation 1
- Never let normal imaging override high clinical suspicion—proceed to surgical exploration regardless 1, 2
Manual Detorsion Considerations
- Manual detorsion by external rotation can be attempted in select cases, but blood flow restoration must be confirmed and surgical exploration with bilateral orchiopexy is still required 6, 5
- This should only be considered as a temporizing measure while preparing for definitive surgery, not as standalone treatment 5
Age-Specific Awareness
- Testicular torsion has a bimodal distribution peaking in neonates and postpubertal boys, but can occur at any age 1
- In prepubertal boys, torsion of testicular appendage is more common, but testicular torsion must still be excluded 1, 2
- History of previous similar episodes occurs in up to 50% of patients, suggesting intermittent torsion requiring prophylactic bilateral orchiopexy 4