Background
- Bimodal incidence
- First peak in first year of life
- Second peak at puberty
- Risk factors
- Undescended testicle
- Bell-clapper deformity
- Half occur during sleep
- May present after scrotal trauma with persistent pain
Salvage Rates for Detorsion Times
Time
|
Rate
|
<6 hrs
|
90-100%
|
6-12 hrs
|
20-50%
|
>24 hrs
|
0-10%
|
Clinical Features
- History:
- Abrupt onset testicular pain associated with nausea or vomiting
- May have previous similar intermittent, self-resolving episodes
- Physical exam:
- Swollen, high-riding testis
- Transverse testicular lie
- Absent cremasteric reflex on affected side (99% sensitivity)
- Ultrasound
- Only indicated for equivocal cases
- Unilateral absence of blood flow
Differential Diagnosis
Evaluation
Work-Up
- Do not delay urologic consultation for work-up
- Consult urology immediately if strongly suspicious for torsion
- Urinalysis
- Ultrasound for equivocal cases
- Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S[1]
- 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 points (Suggesting stat urological consult)
- NPV 100% when <2 points (Suggesting clinical clearance)[2]
- Scores from 2-5 patients require U/S for further assessment
Management
- Manual detorsion (temporizing measure)
- Urological consultation for detorsion and orchipexy
Manual Detorsion
- Not definitive treatment
- Temporizing measure if urologist not immediately available
- Provide parenteral analgesia or perform cord block (grasp cord at external ring and inject 10 mL lidocaine directly into cord)
- "Open the book" by twisting testicle outward and laterally
- Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
- Repeat rotation 2 - 3 times until testicle is detorted and pain decreases
- If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
Disposition
See Also
References
- ↑ Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.
- ↑ 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.