Testicular torsion

Background

• Peak incidence in first year of life, 2nd peak incidence at puberty
• Increased risk: Undescended testicle or Bell-Clapper Deformity
• 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

Clinical Features

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

Differential Diagnosis

Testicular Diagnoses

• Scrotal cellulitis
• Epididymitis
• Fournier gangrene
• Hematocele
• Hydrocele
  • Hydrocele (peds)
• Indirect inguinal hernia
• Inguinal lymph node (Lymphadenitis)
• Orchitis
• Scrotal abscess
• Spermatocele
• Tinea cruris
• Testicular rupture
• Testicular torsion
• Testicular trauma
• Testicular tumor
• Torsion of testicular appendage
• Varicocele
• Pyocele
• Testicular malignancy
• Scrotal wall hematoma

Evaluation

Work-Up

• Urinalysis
• US for equivocal cases
  • Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S
• 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 patients (Suggesting clinical clearance)
• NPV 100% when <2 patients (Suggesting stat urological consult)
• Scores from 2-5 patients require U/S for further assessment

Treatment

• Manual (ED) vs. surgical (urology)

Manual Detorsion

• Indicated if urologist is not immediately available
• Not definitive treatment
  • Patient 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

• Testicular diagnoses
• Testicular ultrasound