Testicular torsion

Background

• Twisting of the spermatic cord causing ischemia of the testicle
• A true urologic emergency — testicular salvage rate >90% if detorsion within 6 hours
• 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

• 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

• Clinical diagnosis — high suspicion = immediate urology consult; do NOT delay for imaging
• Doppler ultrasound — if diagnosis uncertain
  • 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

• Epididymitis
• Fournier gangrene
• Scrotal pain
• Ovarian torsion