Testicular Torsion

Written By: Lynne Yancey
University of Colorado School of Medicine

Edited By: Luan Lawson
Brody School of Medicine at East Carolina University

Objectives

  • List common presenting signs and symptoms of testicular torsion
  • Describe both initial and definitive management of testicular torsion
  • Explain why torsion is an emergent condition and discuss the timeline for salvage of the testicle
Mechanism of torsion. The testis usually twists toward the midline, along the axis of the spermatic cord.

Testicular torsion is caused by the twisting of the testis and spermatic cord within the scrotum, with resulting in occlusion of venous return and and edema. If the It torsion persists, it can result in arterial occlusion and ischemia. Ischemia eventually leads to infarction and, resulting in decreased fertility due to loss of the testicle. Treatment of testicular torsion is a true urologic emergency, thus diagnosis and management and should not be delayed.

Normally the testicle is anchored within the scrotum by the tunica vaginalis, which surrounds the testicle and attaches posteriorly to the scrotal wall and epididymis. The tunica vaginalis consists of a visceral and parietal layer with an interposed potential space. This potential space allows the testicle to rotate about the spermatic cord within the tunica vaginalis if a firm posterior scrotal attachment is lacking. When the tunica vaginalis attaches higher up on the spermatic cord, the testicle can move and twist within the scrotum (“bell-clapper” deformity). This places the testicle and spermatic cord at risk for torsion.

The appendix testes are embryonic remnants that have no known function and are located on the upper pole of the testicle. The appendix testes are prone to torsion as well, and the similar symptoms can be confused with torsion of the testicle.

Initial Actions and Primary Survey

  • Obtain vital signs and IV access.
  • Perform a focused history and physical examination
  • Intravenous pain control
  • Order an ultrasound to assess for the presence or absence of vascular flow if the diagnosis is unclear.
  • Consult urology early if torsion is suspected.

Differential Diagnosis

  • Testicular torsion
  • Torsion of the appendix testis
  • Epididymitis
  • Orchitis
  • Renal colic
  • VaricoceleKidney stone
  • Appendicitis
  • Hernia
  • Hydrocele
  • Testicular trauma

Classic Presentation

Torsion is most common in the first year of life (including the prenatal period) and at puberty, although it can occur at any age. Patients often describe fairly sudden, severe unilateral testicular pain, sometimes radiating into the abdomen, associated with nausea and vomiting. They may also report urgency, frequency, and dysuria. The left testicle is more frequently affected. Torsion may result from direct trauma to the testicle, and the diagnosis may be delayed if the patient?s pain is attributed solely to the injury itself. A small number of patients will describe intermittent testicular pain that resolves spontaneously. This history is highly suspicious for torsion-detorsion and should be referred promptly to a urologist to avoid acute torsion and testicular ischemia and loss.

On physical examination, the patient is often in significant distress, and may have trouble walking due to severe pain. Always examine the unaffected testicle first in both the supine and standing position. The physical examination may be very difficult to perform since the patient frequently experiences a tremendous amount of discomfort. The testicle is usually exquisitely tender and swollen. It may sit higher within the scrotum than the opposite testis, and may have a transverse lie. Prehn?s sign describes the (relief of pain with elevation of the testicle and) was once to be touted as a method to distinguish epididyydimitis from torsion since the pain associated with torsion is usually not relieved with elevation of the testicle (ie, positive Prehn?s = epidiydyimitis). However, this sign is not reliable in differentiating these two entities. Several studies have found loss of the cremasteric reflex to be the most accurate sign of testicular torsion. This reflex is elicited by stroking the ipsilateral thigh which leads to reflex elevation of the ipsilateral testicle by greater than 0.5cm.

Diagnostic Testing

Laboratory analysis of blood and urine is usually not helpful. If infectious epididymitis or orchitis is suspected, it is reasonable to perform a urinalysis or urethral swab for gonorrhea and chlamydia. Caution should be exercised since as many as 30% of patients with torsion will have white blood cells present on the urinalysis. However, do not delay the management of suspected torsion for any lab result.

Ultrasound is the test of choice in the emergency department to diagnose torsion when the clinical diagnosis is not clear. Comparison of the painful testis to the asymptomatic one is key: the painful testicle is usually enlarged and hypoechoic, with decreased blood flow, compared to the asymptomatic side. Twisting of the spermatic cord may be also visible on ultrasound. Complete absence of Doppler flow confirms the diagnosis of torsion, but is a relatively late finding. By contrast, epididymitis is usually associated with increased blood flow to the testicle and the epididymis, as part of the body’s inflammatory response.

Normal testes. The testes have similar density, and blood flow is evident bilaterally.

Testicular torsion. The right testicle (left side of image) is larger and diffusely hypoechoic, indicating edema. (photo courtesy of Dr. John Kendall).

Testicular torsion. No Doppler flow is visible within the right testicle (photo courtesy of Dr. John Kendall).

Epididymitis/orchitis. In contrast to torsion, this testicle demonstrates increased Doppler flow (photo courtesy of Dr. John Kendall).

How do I make the diagnosis?

Testicular torsion is primarily a clinical diagnosis. Take a careful history, and perform as thorough a genitourinary exam as possible. Patients with torsion are often in severe distress, and may not be able to tolerate a thorough exam. Treat your patient?s pain with IV narcotics. Adequate pain management will not only help your patientmake your patient more comfortable, but it may help you you to get a more obtain a more thorough exam. Table 1 summarizes some of the differences between testicular torsion and two other common causes of the acute scrotum: torsion of a testicular appendage and epididyidymitis.

Distinguishing features of testicular torsion, torsion of a testicular appendage, and epididymitis
Age Features of pain Associated signs/sx Physical exam Laboratory testing Ultrasound Treatment Outcome if untreated
Testicular Torsion Bimodal peak: infancy & puberty Entire testicle, onset over hours Nausea Cremasteric reflex abent

Diffusely swollen tender testicle

Not helpful Affected testicule large and hypoechoic compared to asymptomatic side

Decreased flow

Surgical detorsion and bilateral orchiopexy Testicular infarction, decreased fertility
Torsion of testicular appendage 7-14 years Upper pole of testicle, onset over hours to day None Cremasteric reflex present Not helpful Body of testis similar to asymptomatic side with focal hypoechoic area Supportive Infarction and resorption of appendage, no effect on fertility
Epididymitis Adult Epididymis, onset over days Fever, dysuria Cremasteric reflex present

Epididymal tenderness with or without testicular tenderness

WBC, LE, nitrites Body of testis similar to asymptomatic side with hypoechoic epididymis Antibiotics Possible scarring, possible impaired fertility

While ultrasound is the most useful diagnostic modality available to help diagnose torsion, definitive diagnosis is only made at surgery. Do not delay calling a urologist if you suspect torsion.

Treatment

As with any emergency department patient, start with a primary assessment: airway, breathing, and circulation. Anyone with a suspected torsion should have an IV placed. Treat pain and nausea with IV medications, and keep the patient NPO in preparation for admission to the OR.

If you anticipate any delay in getting the patient to the OR, attempt manual detorsionperform a maneuver w which may temporarily restore some blood flow to the testicle: manual detorsion. The procedure is painful, so consider IV sedation or analgesia prior to attempting it. Have the patient lie supine, and stand facing towards the patient?s head. To manually detorse the testicle, grasp it gently and rotate it away from midline, as if you are opening a book. Most torsions involve one or more complete (360°) rotations. Therefore, you may need to make two or three complete rotations of the testicle. When the maneuver is successful, patients report dramatic pain relief within minutes. While most torsions occur toward the patient?s midline, a minority will twist in the opposite direction. Therefore, if it is difficult to untwist in one direction, try untwisting in the opposite direction.

Definitive treatment of testicular torsion is surgical. The testicle must be completely untwisted as soon as possible to restore blood flow. While there is no absolute cutoff to ensure viability, some studies have indicated that the best outcomes are achieved if the testicle is detorsed within 6 hours. If on surgical examination the testicular tissue is obviously necrotic, it may be removed. However, salvage is obviously desired and usually attempted. In addition, bilateral orchiopexy is usually done to prevent future torsion and preserve fertility.

Pearls and Pitfalls

  • To borrow a phrase, time is testicle (and fertility). Call a urologist immediately before the ultrasound is obtained if you suspect the diagnosis.
  • Consider torsion in any patient with testicular trauma who still has pain 1-2 hours after an injury.
  • Ultrasound is most useful if it is performed bilaterally, to compare the asymptomatic testicle to the painful one.
  • While ultrasound is helpful, torsion is primarily a clinical diagnosis. Do not delay management of the patient if ultrasound is not immediately available.

Selected References

  1. Blaivas M, Sierzenski, P. Emergency ultrasonography in the evaluation of the acute scrotum. Academic Emergency Medicine 2001 Jan; 8(1): 85-89.
  2. Silverman M, Schneider RE. Urologic Procedures. In Roberts JR and Hedges JR, ed. Roberts: Clinical Procedures in Emergency Medicine, 5th ed. Philadelphia: Saunders, 2010: 1010.
  3. Schmitz D, Safranek S. Clinical inquiries: How useful is a physical exam in diagnosing testicular torsion?J Fam Pract 2009 Aug; 58(8):433-4.