Testicular torsion

Background

• Peak incidence in first year of life, 2nd peak incidence at puberty
• Consider torsion in setting of scrotal trauma if pain persists >1hr
• Half of all torsions occur during sleep

Salvage Rates for Detorsion Times

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

Diagnosis

• History:
  • Abrupt onset testicular pain a/w N/V
  • May have had intermittent episodes in the past
• Exam:
  • Swollen, high-riding testis w/ transverse lie
  • Absent cremasteric reflex on affected side (99% Sn)
• Ultrasound
  • Only indicated for equivocal cases
  • Unilateral abscence of flow (specific)

Work-Up

• UA
• US for equivocal cases
• Lab workup for surgery

DDx

1. Torsion of Testicular Appendage
2. Epididymitis
3. Testicular mass
4. Incarcerated hernia

Treatment

• Manual (ED) vs. surgical (urology)

Manual Detorsion

• Indicated if urologist is not immediately available
• Not definitive tx
  • Pt still requires emergent urology consult even if successful
• "Open the book" = twist outward and laterally
  • Give parenteral analgesia or perform cord block
    • Prep skin, palpate and grasp cord at external ring and inject 10mL lidocaine directly into cord
  • Hold testicle with left thumb and forefinger
    • Rotate testicle outward 180° in medial to lateral direction
      • Counterclockwise for right testicle and clockwise for left testicle
    • Rotation may need to be repeated 2-3x for complete detorsion/pain relief
    • If difficult to detorse or pain is worse after rotation, try to rotate testicle in opposite direction and observe results.

Disposition

• To OR or urology

See Also

Torsion of Testicular Appendages

Source

Tintinalli, Rosen's, ER atlas