Testicular torsion

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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

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/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

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[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 (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

References

  1. Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.
  2. 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.