Testicular torsion: Difference between revisions

(Add MedicationDose entry (lidocaine cord block) with SMW annotations)
Tag: Reverted
(Major expansion: manual detorsion technique, TWIST score, imaging caveats, peer-reviewed references)
Tag: Reverted
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==Background==
==Background==
[[File:Gray1144.png|thumb|Scrotal anatomy]]
*Twisting of the spermatic cord causing ischemia of the testicle
[[File:Figure 28 01 03.jpg|thumb|Testicular 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: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)]]
*After 12 hours: salvage rate drops to ~50%; after 24 hours: <10%
*Must consider as a ddx in all acute scrotal pain
*Bimodal incidence: neonates and adolescents (peak 12-18 years)
**May lead to testicular ischemia and subsequent infertility
*Most common cause of acute testicular pain requiring surgery in males <25
*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===
==Types==
*Mechanical: Exertional/exercise, trauma
*'''Intravaginal''' (most common) — within tunica vaginalis; associated with "bell clapper" deformity
*Testicular masses
*'''Extravaginal''' — entire testis and tunica rotate; typically neonatal
*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==
*History:
*'''Sudden onset''', severe unilateral testicular pain
**Abrupt onset testicular pain associated with nausea or [[vomiting]]
*Nausea, vomiting (very common)
**May have previous similar intermittent, self-resolving episodes
*'''High-riding''' testicle with '''horizontal lie'''
**May present after scrotal trauma with persistent pain
*Absent '''cremasteric reflex''' on affected side (most sensitive PE finding; >99% sensitivity in some studies, but absence does not rule out torsion)
**May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain
*Diffuse testicular swelling and tenderness
*Physical exam:
*Negative Prehn sign (elevation of testis does not relieve pain) — unreliable
**Swollen, tender, high-riding testis
*May have history of prior intermittent episodes (intermittent torsion-detorsion)
**Transverse testicular lie
*No dysuria, discharge, or fever (suggests alternative diagnosis)
**Absent cremasteric reflex on affected side (99% sensitivity)


==Differential Diagnosis==
==Differential Diagnosis==
{{Testicular DDX}}
*[[Epididymitis]] / [[Epididymo-orchitis]]
*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==
===Work-Up===
*'''Clinical diagnosis''' — high suspicion = immediate urology consult; do NOT delay for imaging
*Do not delay urologic consultation for 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>
**Consult urology immediately if strongly suspicious for torsion
**Decreased or absent blood flow to affected testis
*[[Urinalysis]]
**Sensitivity ~88-100%, specificity ~90-100%
*[[testicular ultrasound|Ultrasound]] for equivocal cases
**Normal flow does NOT completely exclude torsion (intermittent or early)
**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>
**'''If high clinical suspicion, proceed to OR despite normal ultrasound'''
*Lab workup for surgery
*'''Urinalysis''' — typically normal in torsion (pyuria suggests [[Epididymitis|epididymitis]])
 
*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===
*Not definitive treatment. Temporizing measure if urologist not immediately available
*Attempt if surgical intervention will be delayed
*May require conscious sedation or parenteral [[analgesia]] if severe pain is anticipated
*'''Open the book''' technique: rotate the affected testicle medial-to-lateral (as opening a book)
#May perform cord block
**Typically requires 1-3 full rotations (360-1080 degrees)
#*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>
*Successful detorsion: immediate pain relief and return of normal testicular position
#"Open the book" by twisting testicle outward and laterally
*If pain worsens, try rotating in opposite direction
#*Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
*Successful manual detorsion still requires surgical orchidopexy
#Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases
#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


===Surgical Management===
*'''Emergent urology consultation''' for surgical exploration and orchidopexy
*Bilateral orchidopexy performed (bell clapper deformity is bilateral in ~80%)
*If testis is nonviable: orchiectomy


==Medication Dosing==
===Supportive Care===
{{MedicationDose
*IV analgesics (do NOT withhold — pain does not aid diagnosis once torsion suspected)
| drug = Lidocaine
*Antiemetics
| dose = 10mL injected around spermatic cord
*NPO in anticipation of surgery
| route = Local injection
| context = Spermatic cord block for manual detorsion
| indication = Testicular torsion
| population = Adult
| notes = Create skin wheal, inject into anterior, lateral, and medial portions of cord
}}


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


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


==References==
==References==
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[[Category:Urology]]
[[Category:Urology]]
[[Category:Pediatrics]]

Revision as of 18:33, 21 March 2026

Background

  • Twisting of the spermatic cord causing ischemia of the testicle
  • A true urologic emergency — testicular salvage rate >90% if detorsion within 6 hours[1]
  • After 12 hours: salvage rate drops to ~50%; after 24 hours: <10%
  • Bimodal incidence: neonates and adolescents (peak 12-18 years)
  • Most common cause of acute testicular pain requiring surgery in males <25

Types

  • Intravaginal (most common) — within tunica vaginalis; associated with "bell clapper" deformity
  • Extravaginal — entire testis and tunica rotate; typically neonatal

Clinical Features

  • Sudden onset, severe unilateral testicular pain
  • Nausea, vomiting (very common)
  • High-riding testicle with horizontal lie
  • Absent cremasteric reflex on affected side (most sensitive PE finding; >99% sensitivity in some studies, but absence does not rule out torsion)
  • Diffuse testicular swelling and tenderness
  • Negative Prehn sign (elevation of testis does not relieve pain) — unreliable
  • May have history of prior intermittent episodes (intermittent torsion-detorsion)
  • No dysuria, discharge, or fever (suggests alternative diagnosis)

Differential Diagnosis

Evaluation

  • Clinical diagnosis — high suspicion = immediate urology consult; do NOT delay for imaging
  • Doppler ultrasound — if diagnosis uncertain[2]
    • Decreased or absent blood flow to affected testis
    • Sensitivity ~88-100%, specificity ~90-100%
    • Normal flow does NOT completely exclude torsion (intermittent or early)
    • If high clinical suspicion, proceed to OR despite normal ultrasound
  • Urinalysis — typically normal in torsion (pyuria suggests epididymitis)
  • TWIST score (Testicular Workup for Ischemia and Suspected Torsion) can risk-stratify in pediatrics

Management

Manual Detorsion

  • Attempt if surgical intervention will be delayed
  • Open the book technique: rotate the affected testicle medial-to-lateral (as opening a book)
    • Typically requires 1-3 full rotations (360-1080 degrees)
  • Successful detorsion: immediate pain relief and return of normal testicular position
  • If pain worsens, try rotating in opposite direction
  • Successful manual detorsion still requires surgical orchidopexy

Surgical Management

  • Emergent urology consultation for surgical exploration and orchidopexy
  • 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

  • All suspected testicular torsion requires emergent urology consultation and OR
  • Do not discharge without urology evaluation

See Also

References

  1. ↑ Sharp VJ, et al. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840. PMID 24364549.
  2. ↑ 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.
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