Testicular torsion: Difference between revisions

(Major expansion: manual detorsion technique, TWIST score, imaging caveats, peer-reviewed references)
Tag: Reverted
(Reverted edits by Danbot (talk) to last revision by Patricklin)
Tag: Rollback
 
(One intermediate revision by one other user not shown)
Line 1: Line 1:
==Background==
==Background==
*Twisting of the spermatic cord causing ischemia of the testicle
[[File:Gray1144.png|thumb|Scrotal anatomy]]
*A '''true urologic emergency''' — testicular salvage rate >90% if detorsion within 6 hours<ref name="sharp">Sharp VJ, et al. Testicular torsion: diagnosis, evaluation, and management. ''Am Fam Physician''. 2013;88(12):835-840. PMID 24364549.</ref>
[[File:Figure 28 01 03.jpg|thumb|Testicular anatomy]]
*After 12 hours: salvage rate drops to ~50%; after 24 hours: <10%
[[File:Illu testis surface.jpg|thumb|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]]
*Bimodal incidence: neonates and adolescents (peak 12-18 years)
*Must consider as a ddx in all acute scrotal pain
*Most common cause of acute testicular pain requiring surgery in males <25
**May lead to testicular ischemia and subsequent infertility
*A clear precipitating factor is not necessary identified; half occur during sleep
*Bimodal incidence
**First peak in first year of life
**Second peak at puberty


==Types==
===Risk factors===
*'''Intravaginal''' (most common) — within tunica vaginalis; associated with "bell clapper" deformity
*Mechanical: Exertional/exercise, trauma
*'''Extravaginal''' — entire testis and tunica rotate; typically neonatal
*Testicular masses
*Undescended testicle
*Bell-clapper deformity
 
 
'''Salvage Rates for Detorsion Times'''  
 
{| class="wikitable"
|-
| '''Time'''
| '''Rate'''
|-
| <6 hrs
| 90-100%
|-
| 6-12 hrs
| 20-50%
|-
| >24 hrs
| 0-10%
|}


==Clinical Features==
==Clinical Features==
*'''Sudden onset''', severe unilateral testicular pain
*History:
*Nausea, vomiting (very common)
**Abrupt onset testicular pain associated with nausea or [[vomiting]]
*'''High-riding''' testicle with '''horizontal lie'''
**May have previous similar intermittent, self-resolving episodes
*Absent '''cremasteric reflex''' on affected side (most sensitive PE finding; >99% sensitivity in some studies, but absence does not rule out torsion)
**May present after scrotal trauma with persistent pain
*Diffuse testicular swelling and tenderness
**May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain
*Negative Prehn sign (elevation of testis does not relieve pain) — unreliable
*Physical exam:
*May have history of prior intermittent episodes (intermittent torsion-detorsion)
**Swollen, tender, high-riding testis
*No dysuria, discharge, or fever (suggests alternative diagnosis)
**Transverse testicular lie  
**Absent cremasteric reflex on affected side (99% sensitivity)


==Differential Diagnosis==
==Differential Diagnosis==
*[[Epididymitis]] / [[Epididymo-orchitis]]
{{Testicular DDX}}
*Torsion of appendix testis ('''blue dot sign''')
*[[Inguinal hernia]] (incarcerated)
*Testicular tumor
*Testicular rupture / trauma
*Hydrocele
*Varicocele
*Henoch-Schönlein purpura (in children)
*[[Fournier gangrene]]


==Evaluation==
==Evaluation==
*'''Clinical diagnosis''' — high suspicion = immediate urology consult; do NOT delay for imaging
===Work-Up===
*'''Doppler ultrasound''' — if diagnosis uncertain<ref name="beni">Beni-Israel T, et al. Clinical predictors for testicular torsion as seen in the pediatric ED. ''Am J Emerg Med''. 2010;28(7):786-789. PMID 20837253.</ref>
*Do not delay urologic consultation for work-up
**Decreased or absent blood flow to affected testis
**Consult urology immediately if strongly suspicious for torsion
**Sensitivity ~88-100%, specificity ~90-100%
*[[Urinalysis]]
**Normal flow does NOT completely exclude torsion (intermittent or early)
*[[testicular ultrasound|Ultrasound]] for equivocal cases
**'''If high clinical suspicion, proceed to OR despite normal ultrasound'''
**Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S<ref>Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.</ref>
*'''Urinalysis''' — typically normal in torsion (pyuria suggests [[Epididymitis|epididymitis]])
*Lab workup for surgery
*TWIST score (Testicular Workup for Ischemia and Suspected Torsion) can risk-stratify in pediatrics
 
===TWIST Score===
*Proposed score for assessing testicular torsion in children
 
{| class="wikitable"
|-
! Finding !! Points
|-
| Testicular swelling || 2
|-
| Hard testicle || 2
|-
| Absent cremasteric reflex || 1
|-
| Nausea or vomiting || 1
|-
| High-riding testicle|| 1
|}
*PPV 100% when >5 points (Suggesting stat urological consult)
*NPV 100% when <2 points (Suggesting clinical clearance)<ref>Barbosa, JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.</ref>
*Scores from 2-5 patients require U/S for further assessment
 
===Diagnosis===
*[[testicular ultrasound|Ultrasound]]  
**Only indicated for equivocal cases
**Unilateral absence of blood flow


==Management==
==Management==
*Manual detorsion (temporizing measure)
**Typically done if surgical management is not immediately available
*Urological consultation for detorsion and orchipexy
**Surgical exploration is the gold standard; without surgery, difficult to determine if manual detorsion has worked
===Manual Detorsion===
===Manual Detorsion===
*Attempt if surgical intervention will be delayed
*Not definitive treatment. Temporizing measure if urologist not immediately available
*'''Open the book''' technique: rotate the affected testicle medial-to-lateral (as opening a book)
*May require conscious sedation or parenteral [[analgesia]] if severe pain is anticipated
**Typically requires 1-3 full rotations (360-1080 degrees)
#May perform cord block
*Successful detorsion: immediate pain relief and return of normal testicular position
#*Grasp spermatic cord as it enters scrotum, track up to external ring, create skin wheal, and inject 10 mL [[lidocaine]] directly into the anterior, lateral, medial portions of cord  <ref>Gordon J, Rifenburg RP. Spermatic Cord Anesthesia Block: An Old Technique Re-imaged. West J Emerg Med. 2016 Nov;17(6):811-813. doi: 10.5811/westjem.2016.8.31017. Epub 2016 Sep 13. PMID: 27833695; PMCID: PMC5102614.</ref>
*If pain worsens, try rotating in opposite direction
#"Open the book" by twisting testicle outward and laterally
*Successful manual detorsion still requires surgical orchidopexy
#*Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
 
#Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases
===Surgical Management===
#If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
*'''Emergent urology consultation''' for surgical exploration and orchidopexy
#*In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed
*Bilateral orchidopexy performed (bell clapper deformity is bilateral in ~80%)
*If testis is nonviable: orchiectomy
 
===Supportive Care===
*IV analgesics (do NOT withhold — pain does not aid diagnosis once torsion suspected)
*Antiemetics
*NPO in anticipation of surgery


==Disposition==
==Disposition==
*'''All suspected testicular torsion requires emergent urology consultation and OR'''
*To OR or urology  
*Do not discharge without urology evaluation


==See Also==
==See Also==
*[[Epididymitis]]
*[[Testicular diagnoses]]
*[[Fournier gangrene]]
*[[Testicular ultrasound]]
*[[Scrotal pain]]
*[[Ovarian torsion]]


==References==
==References==
Line 74: Line 112:


[[Category:Urology]]
[[Category:Urology]]
[[Category:Pediatrics]]

Latest revision as of 18:58, 25 March 2026

Background

Scrotal anatomy
Testicular anatomy
1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)
  • Must consider as a ddx in all acute scrotal pain
    • May lead to testicular ischemia and subsequent infertility
  • A clear precipitating factor is not necessary identified; half occur during sleep
  • Bimodal incidence
    • First peak in first year of life
    • Second peak at puberty

Risk factors

  • Mechanical: Exertional/exercise, trauma
  • Testicular masses
  • Undescended testicle
  • Bell-clapper deformity


Salvage Rates for Detorsion Times

Time Rate
<6 hrs 90-100%
6-12 hrs 20-50%
>24 hrs 0-10%

Clinical Features

  • History:
    • Abrupt onset testicular pain associated with nausea or vomiting
    • May have previous similar intermittent, self-resolving episodes
    • May present after scrotal trauma with persistent pain
    • May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain
  • Physical exam:
    • Swollen, tender, high-riding testis
    • Transverse testicular lie
    • Absent cremasteric reflex on affected side (99% sensitivity)

Differential Diagnosis

Testicular Diagnoses

Evaluation

Work-Up

  • Do not delay urologic consultation for work-up
    • Consult urology immediately if strongly suspicious for torsion
  • Urinalysis
  • Ultrasound for equivocal cases
    • Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S[1]
  • Lab workup for surgery

TWIST Score

  • Proposed score for assessing testicular torsion in children
Finding Points
Testicular swelling 2
Hard testicle 2
Absent cremasteric reflex 1
Nausea or vomiting 1
High-riding testicle 1
  • PPV 100% when >5 points (Suggesting stat urological consult)
  • NPV 100% when <2 points (Suggesting clinical clearance)[2]
  • Scores from 2-5 patients require U/S for further assessment

Diagnosis

  • Ultrasound
    • Only indicated for equivocal cases
    • Unilateral absence of blood flow

Management

  • Manual detorsion (temporizing measure)
    • Typically done if surgical management is not immediately available
  • Urological consultation for detorsion and orchipexy
    • Surgical exploration is the gold standard; without surgery, difficult to determine if manual detorsion has worked

Manual Detorsion

  • Not definitive treatment. Temporizing measure if urologist not immediately available
  • May require conscious sedation or parenteral analgesia if severe pain is anticipated
  1. May perform cord block
    • Grasp spermatic cord as it enters scrotum, track up to external ring, create skin wheal, and inject 10 mL lidocaine directly into the anterior, lateral, medial portions of cord [3]
  2. "Open the book" by twisting testicle outward and laterally
    • Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
  3. Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases
  4. If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
    • In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed

Disposition

  • To OR or urology

See Also

References

  1. ↑ Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.
  2. ↑ Barbosa, JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.
  3. ↑ Gordon J, Rifenburg RP. Spermatic Cord Anesthesia Block: An Old Technique Re-imaged. West J Emerg Med. 2016 Nov;17(6):811-813. doi: 10.5811/westjem.2016.8.31017. Epub 2016 Sep 13. PMID: 27833695; PMCID: PMC5102614.
Retrieved from "https://www.wikem.org/w/index.php?title=Testicular_torsion&oldid=389816"