Testicular torsion

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

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

• 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
• 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)
• 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

1. Provide parenteral analgesia or perform cord block (grasp cord at external ring and inject 10 mL lidocaine directly into cord)
2. "Open the book" by twisting testicle outward and laterally
   • Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
3. Repeat rotation 2 - 3 times until testicle is detorted and pain decreases
4. If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction

Disposition

• To OR or urology

See Also

• Testicular diagnoses
• Testicular ultrasound