From the Guidelines
Testicular torsion reversal requires immediate emergency surgical intervention called manual detorsion followed by orchiopexy, as the success rate for saving the testicle decreases dramatically with time, with nearly 100% success if treated within 6 hours, but dropping to less than 20% after 24 hours 1. If testicular torsion is suspected, the patient should go to the emergency room immediately as the testicle can suffer permanent damage after just 6 hours of reduced blood flow. Manual detorsion involves rotating the affected testicle outward (like opening a book) to untwist the spermatic cord and restore blood flow. This procedure is typically performed by a urologist under anesthesia. Following successful detorsion, orchiopexy surgery is performed to secure both testicles to the scrotum wall to prevent future torsion. The diagnosis of testicular torsion can be supported by ultrasound findings, including an enlarged heterogeneous testis, ipsilateral hydrocele, skin thickening, and no color Doppler flow in the testis or spermatic cord 1. However, a twisted spermatic cord, also known as the "whirlpool sign," is the most specific US sign of torsion 1. Pain relief with analgesics is important during treatment, but addressing the torsion itself is the priority. Testicular torsion occurs when the spermatic cord twists, cutting off blood supply to the testicle, causing severe pain, swelling, and potential tissue death if not promptly treated. Key points to consider in the diagnosis and treatment of testicular torsion include:
- Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss 1
- A validated clinical risk scoring system, Testicular Workup for Ischemia and Suspected Torsion Score, has shown high positive predictive value, but has not been widely adopted 1
- Ultrasound is the established first-line imaging modality for acute scrotal disease and can be used to diagnose most scrotal disorders when combined with clinical history and physical examination 1
From the Research
Testicular Torsion Reversal
- Testicular torsion is a surgical emergency that requires prompt treatment to avoid testicular loss 2, 3
- The optimal time frame for treatment is less than six hours after the onset of symptoms 2
- Manual detorsion by external rotation of the testis can be successful, but restoration of blood flow must be confirmed following the maneuver 2
- Surgical exploration provides definitive treatment for the affected testis by orchiopexy and allows for prophylactic orchiopexy of the contralateral testis 2, 4
Surgical Techniques
- There is limited evidence in favor of any one surgical technique for acute testicular torsion 4
- Different techniques differ in incision and/or type of suture and/or point(s) of fixation 4
- Postoperative complications, such as scrotal abscess and stitch abscess, have been reported 4
Predictors of Surgical Outcomes
- Wait time to surgery positively correlates with orchiectomy 5
- Patients with orchiectomies had longer wait times for surgery and greater degrees of torsion than those with orchiopexies 5
- The presence of the bell clapper deformity moderated the relationship between temperature and testicular torsion 5
Management and Training
- Suspected testicular torsion is a surgical emergency that requires urgent scrotal exploration 6
- There is variability in the management of suspected testicular torsion between urology and surgical trainees 6
- Urology trainees were more aware of evidence regarding chronic pain and infertility following testicular fixation than surgical trainees 6