What are the implications of a partial testicular torsion detected on Ultrasonography (US)?

From the Guidelines

Partial testicular torsion detected on ultrasound requires immediate urological consultation for potential surgical intervention. This condition represents an incomplete twisting of the spermatic cord that can progress to complete torsion, causing testicular ischemia and potential loss of the testicle. The diagnosis of partial testicular torsion can be challenging, but ultrasound is the established first-line imaging modality for acute scrotal disease and can be used to diagnose most scrotal disorders promptly and with high accuracy 1.

Key Considerations

• The American College of Radiology Appropriateness Criteria recommend ultrasound as the first-line imaging modality for acute scrotal disease 1.
• Spectral Doppler analysis can help diagnose partial testicular torsion by assessing the amplitude of the spectral Doppler arterial waveform and its appearance relative to the contralateral testicle or a different region within the same testicle 1.
• The risk of progression to complete torsion is significant, and time is critical, with the best outcomes occurring when treatment is provided within 6 hours of symptom onset 1.
• While awaiting specialist evaluation, manual detorsion can be attempted by rotating the affected testicle outward (like opening a book) to potentially restore blood flow temporarily.
• Pain management with NSAIDs such as ibuprofen 400-600mg every 6 hours may help with discomfort.

Treatment Approach

• The definitive treatment typically involves surgical exploration with orchiopexy (fixation of both testes to prevent future torsion) even for partial torsion 1.
• Ultrasound findings, including an enlarged heterogeneous testis, ipsilateral hydrocele, skin thickening, and no color Doppler flow in the testis or spermatic cord, can support the diagnosis of testicular torsion 1.
• Correlation with clinical data, including the presence of fever, waxing and waning pain, and laboratory markers for infection, must be integrated in the clinical assessment to distinguish between testicular torsion and epididymoorchitis 1.

From the Research

Detection and Diagnosis

• Partial testicular torsion can be detected on ultrasound (US) as stated in the studies 2, 3, 4, 5.
• The use of color Doppler ultrasound can confirm complete manual detorsion and ensure the restoration of blood flow to the testicle 2, 5.
• Ultrasound-assisted manual testicular detorsion is a non-invasive, simple, quick, safe, and effective maneuver that can rapidly restore testicular blood flow 3.

Ultrasound Findings

• Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are sonographic findings associated with testicular torsion 4.
• The direction of testicular torsion, i.e., inner or outer direction, and the degree of spermatic cord twist are indications for manual detorsion 4.
• The presence of the whirlpool sign and the degree and extent of perfusion of the affected testis are used to determine whether the treatment was successful 4.

Management and Treatment

• Manual detorsion is a simple, immediately available, and maximizes testis salvage procedure that can be performed at the bedside 2, 3, 5.
• A successful manual detorsion maneuver permits nonemergency orchiopexy 5.
• Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum 6.