Testicular torsion

Definition: Twisting of the spermatic cord leading to decreased blood flow to the testicle resulting in ischemia, infarction and potentially, tissue necrosis.

Epidemiology:

• Most common cause of acute scrotal pain in prepubertal boys
• Torsion present in 3.2% of all children presenting to the ED with scrotal pain
• Bimodal frequency: peaks in 1st year of life and again at puberty
• Risk factors: History of cryptorchidism, horizontal testicular lie, increased spermatic cord length

Pathophysiology: 

• Anatomical defect in the tunica vaginalis allowing the testicle to rotate when the cremasteric muscle contracts
• Twisting of the testicle initially causes compromised venous return and can lead to arterial obstruction, ischemia and tissue necrosis
• Testicle can rotate from 180^o to 720^o
• Longer duration of torsion increases the risk of tissue necrosis
  • Torsion recognized within 6 hours has an 80-100% salvage rate
  • Persistent symptoms > 24 hours has a nearly 0% salvage rate

Differential Diagnosis

• Hydrocele
• Epididymitis
• Epididymorchitis
• Trauma
• Inguinal hernia
• Testicular tumor

Clinical Presentation

“No discriminating features, in either history or examination conclusively differentiate the correct diagnosis” 

History

• Acute sudden onset of scrotal pain
• Up to 20% of patients will have abdominal or flank pain alone 
• Nausea and vomiting
• Profound diffuse tenderness and swelling
• History of blunt trauma (~ 10% of patients)
• History of similar pain in the past
• Often occur a few hours after phsyical activity or minor trauma
• Intermittent testicular torsion may presnt with sudden waking during the night – may see persistence of swelling hydrocele, erythema
• Presentation is often delayed (mean time to presentation 9.5 hours)
• Duration of symptoms should NOT guide management
  • Historically, believed that symptoms > 24 hours inconsistent with salvageable tissue
  • However, testicle may torse + detorse making it difficult to know how long ischemia present

Physical Examination

• Unilateral tender, firm testicle
• Scrotal erythema, edema and swelling
• Position of testis- High riding or horizontal
  • Affected testicle typically higher than the unaffected one. OR = 58.8
• Loss of cremasteric reflex
  • Previously thought to be 100% sensitive and highly specific
  • 30% of males with normal testicles will have an absent cremasteric reflex 
  • Studies report varying sensitivities as low as 60%
• Horizontal (instead of vertical) testicular lie

Diagnosis

• The diagnosis of testicular torsion should be pursued in any patient with acute scrotal pain. Physical exam, history and imaging all have significant limitations.
• In patients with a high suspicion for torsion, emergent surgical consultation should not be delayed by diagnostic imaging as “time is testicle”
• Scrotal Ultrasound
  • Standard imaging technique
  • Diagnostic characteristics
    • Sensitivity: 88 – 100% (+ Lr = 8.8 – 10)
    • Specificity: 90% 
    • (+) LR = 8.8-10, (-) LR = 0.13
  • Findings
    • A torsed testicle will be hypoechoic, heterogeneous and enlarged
    • Color doppler will demonstrate decreased or absent blood flow
    • A partially-torsed testicle may have arterial flow but no venous flow, or may show an abnormal high-resistance pattern of arterial flow
    • A testicle that has recently de-torsed will appear enlarged and hyperemic
  • Due to the relatively low sensitivity, a negative color doppler ultrasound does not always rule out the disease
  • Examination of the spermatic cord for twisting increases the false negative rate improving the utility of ultrasound to rule out the diagnosis

Ultrasound Images of Torsion

Right Testicle with Decreased Flow on Color Doppler – www.ultrasoundcases.info	Right Testicle with Swelling and Decreased Flow on Color Doppler – Radiopaedia.com	Left Testicle Hypoechoic and Swollen – www.radiologyassistant.nl

Management: 

• ALL patients with suspicion for testicular torsion should have immediate consultation with a urologist for potential operative exploration and repair.
  • Testicular salvage is time-dependent
    • most testicles remain viable if they are surgically detorsed within 6 hours of the onset of symptoms
    • non-viability 12 hours post-torsion is around 75%
  • intervention should not be withheld even if the pain has been ongoing for more than 6 hours as current literature suggests that there is still a possibility of salvage for patients presenting up to 48 hours post-torsion
  • 
• Establish IV access and provide analgesia
• Manual detorsion
  • Can be attempted if urology consultation is not immediately available
  • May be successful in 25-80% of testicular torsion cases (Rosen’s 2014)
  • Procedure
    • Place patient supine
    • Provider stands at the patients feet
    • Apply “open book” rotation: rotate affected testicle away from midline
    • Rotation required may be anywhere from 180^o – 720^o
  • Up to 1/3 of patients will be torsed in the “opposite” direction
  • After manual detorsion, surgery is still required to perform bilateral orchidopexies

Take Home Points

• Consider the diagnosis of testicular torsion in all patients with acute testicular pain
• Testicular torsion is a surgical emergency that requires immediate urologic consultation to increase the rate of tissue salvage.
• History, physical examination and ultrasound are all flawed in making the diagnosis. The gold standard is surgical exploration
• Consider manual detorsion in patients where consultation will be delayed