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 (Ben-Israel 2010)
  • 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:Torsion Cartoon Image

  • 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 180o to 720o
  • 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” (Sidler 1997)

History

  • Sudden onset of scrotal pain (less frequently, abdominal or inguinal pain)
  • Nausea and vomiting
  • History of blunt trauma (~ 10% of patients)
  • History of similar pain in the past
  • Presentation is often delayed (mean time to presentation 9.5 hours) (Rosen’s)
  • 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
  • Affected testicle typically higher than the unaffected one. OR = 58.8 (Ben-Israel 2010)
  • 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% (Mellick 2012)
  • 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

Management:

  • ALL patients with suspicion for testicular torsion should have immediate consultation with a urologist for potential operative exploration and repair.
  • 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 180o – 720o
    • Regardless of the success of manual detorsion, all patients will require surgical evaluation
Surgical Evaluation - www.sages.org

Surgical Evaluation – www.sages.org

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

References

Ben-Israel T et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-789. PMID: 20837255

Sidler D et al. A 25-year review of the acute scrotum in children. S Afr Med J. 1997;87(12) 1696-8. PMID: 9497837

Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: 22217895

Ban KM, Easter JS: Selected Urologic Problems; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 99: p 1326-1356.