Testicular torsion: Difference between revisions

(Major expansion: manual detorsion technique, TWIST score, imaging caveats, peer-reviewed references)
Tag: Reverted
(Strip excess bold text - keep only critical safety emphasis)
Tag: Reverted
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==Types==
==Types==
*'''Intravaginal''' (most common) — within tunica vaginalis; associated with "bell clapper" deformity
*Intravaginal (most common) — within tunica vaginalis; associated with "bell clapper" deformity
*'''Extravaginal''' — entire testis and tunica rotate; typically neonatal
*Extravaginal — entire testis and tunica rotate; typically neonatal


==Clinical Features==
==Clinical Features==
*'''Sudden onset''', severe unilateral testicular pain
*Sudden onset, severe unilateral testicular pain
*Nausea, vomiting (very common)
*Nausea, vomiting (very common)
*'''High-riding''' testicle with '''horizontal lie'''
*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)
*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
*Diffuse testicular swelling and tenderness
*Negative Prehn sign (elevation of testis does not relieve pain) — unreliable
*Negative Prehn sign (elevation of testis does not relieve pain) — unreliable
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==Differential Diagnosis==
==Differential Diagnosis==
*[[Epididymitis]] / [[Epididymo-orchitis]]
*[[Epididymitis]] / [[Epididymo-orchitis]]
*Torsion of appendix testis ('''blue dot sign''')
*Torsion of appendix testis (blue dot sign)
*[[Inguinal hernia]] (incarcerated)
*[[Inguinal hernia]] (incarcerated)
*Testicular tumor
*Testicular tumor
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==Evaluation==
==Evaluation==
*'''Clinical diagnosis''' — high suspicion = immediate urology consult; do NOT delay for imaging
*'''Clinical diagnosis''' — high suspicion = immediate urology consult; do NOT delay for imaging
*'''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>
*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>
**Decreased or absent blood flow to affected testis
**Decreased or absent blood flow to affected testis
**Sensitivity ~88-100%, specificity ~90-100%
**Sensitivity ~88-100%, specificity ~90-100%
**Normal flow does NOT completely exclude torsion (intermittent or early)
**Normal flow does NOT completely exclude torsion (intermittent or early)
**'''If high clinical suspicion, proceed to OR despite normal ultrasound'''
**If high clinical suspicion, proceed to OR despite normal ultrasound
*'''Urinalysis''' — typically normal in torsion (pyuria suggests [[Epididymitis|epididymitis]])
*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 (Testicular Workup for Ischemia and Suspected Torsion) can risk-stratify in pediatrics


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===Manual Detorsion===
===Manual Detorsion===
*Attempt if surgical intervention will be delayed
*Attempt if surgical intervention will be delayed
*'''Open the book''' technique: rotate the affected testicle medial-to-lateral (as opening a book)
*Open the book technique: rotate the affected testicle medial-to-lateral (as opening a book)
**Typically requires 1-3 full rotations (360-1080 degrees)
**Typically requires 1-3 full rotations (360-1080 degrees)
*Successful detorsion: immediate pain relief and return of normal testicular position
*Successful detorsion: immediate pain relief and return of normal testicular position
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===Surgical Management===
===Surgical Management===
*'''Emergent urology consultation''' for surgical exploration and orchidopexy
*Emergent urology consultation for surgical exploration and orchidopexy
*Bilateral orchidopexy performed (bell clapper deformity is bilateral in ~80%)
*Bilateral orchidopexy performed (bell clapper deformity is bilateral in ~80%)
*If testis is nonviable: orchiectomy
*If testis is nonviable: orchiectomy
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==Disposition==
==Disposition==
*'''All suspected testicular torsion requires emergent urology consultation and OR'''
*All suspected testicular torsion requires emergent urology consultation and OR
*Do not discharge without urology evaluation
*Do not discharge without urology evaluation


Revision as of 09:23, 22 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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