Testicular Torsion


Article Author:
Michael Schick


Article Editor:
Britni Sternard


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/4/2019 4:03:50 PM

Introduction

Scrotal complaints are relatively common in the emergency department, comprising at least 0.5% of all emergency department visits. Testicular torsion is a time-dependent diagnosis, a true urologic emergency, and early evaluation can assist in urologic intervention to prevent testicular loss. Ultrasound is the ideal imaging modality to evaluate the scrotal contents. [1][2][3] 

Etiology

The majority of cases occur in younger patients (< 25 years old) and are usually due to a congenital abnormality of the processus vaginalis. The history of onset may be spontaneous, exertional, or, in fewer instances, associated with trauma. Testicular torsion accounts for roughly one-quarter of scrotal complaints that present to the emergency department. [4]

Epidemiology

The majority of cases occur in the adolescent age range (during periods of growth) but can occur at any age as well as pre- or perinatal. Testicular torsion is the most significant cause of testicular loss.

Pathophysiology

As the testicle twists around the spermatic cord, venous blood flow is cut off, leading to venous congestion and ischemia of the testicle. The testicle will become tender, swollen, and possibly erythematous. As the testicle further twists, arterial blood supply is cut off which leads to further testicular ischemia and eventually necrosis. [5]

History and Physical

Testicular torsion often presents as abrupt onset of unilateral scrotal pain. The pain may be constant or intermittent, but not positional. The patient may have associated symptoms of nausea or vomiting. There may be associated lower abdominal and inguinal pain, or alternatively, these may be the presenting complaint rather than scrotal pain. 

The testicle may be in an abnormal or transverse lie and may be in the high position. The testicle may be swollen, erythematous, and have an absence of the normal cremasteric reflex; however, it should be noted that the presence of absence of the cremasteric reflex is not as sensitive as once thought. Additionally, the cremasteric reflex is unreliable in young patients, especially those less than one year old. 

Torsion of the testicular appendages are more common and not dangerous. During early onset, this may be differentiated from testicular torsion by maximal tenderness to palpation near the head of the epididymis or testis, an isolated tender nodule, and/or a blue dot appearance on the testis. The characteristics blue dot is due to the cyanotic torsed appendage.  The testicular appendage tends to calcify and degenerate over two weeks, and typically no surgical intervention is required. 

Other differential diagnoses to be considered are epididymitis, orchitis, inguinal hernia, symptomatic hydrocele, testicular necrosis of other etiology, and scrotal hematoma. 

Evaluation

Ultrasound is the primary diagnostic modality beyond physical exam. Ultrasound for testicular torsion is approximately 93% sensitive and 100% specific. Trained sonographers should perform this exam in a timely manner. The point-of-care ultrasound technique to evaluate the testicle involves the high-frequency transducer (5 to 10 MHz), ample ultrasound gel, and proper patient positioning. The process is described in brief below: 

  1. Place the patient supine and frog-legged with a towel under the scrotum for support. Using ample gel and minimal pressure, evaluate the unaffected testicle first.  
  2. Scan the testicle in its entirety in both the transverse and longitudinal planes. Scan with gray scale first while noting the presence of fluid collections and testicular texture. A normal testicular is around 4 x 3 x 2.5cm. In the longitudinal plan or long axis, the testicle appears as an oval structure with homogenous echotexture and smooth rounded borders. In the transverse plan or short axis, the testicle appears as a circular structure with homogenous echotexture and smooth rounded borders. Side by side comparison of the testicles is critical to evaluate for size, fluid collections, changes of echotexture, and discrepancies of color Doppler. If the testicle is torsed, there will often be a hydrocele present with a testicle with reduced color or power flow.

Color flow doppler must be applied to both the affected and unaffected testicle of the patient. Begin with the unaffected testicle to gain a sense of what normal vascular flow looks like in this particular patient. Power Doppler is useful in the evaluation of testicular vascular flow as well. Power Doppler has a greater sensitivity for vascular flow, but does not allow the examiner to discern between arterial and venous flow.  

Doppler can be employed to evaluate for both venous and arterial flow by placing the Doppler gate on areas of vascular flow and evaluating for both venous and arterial Doppler waveforms. Arterial waveforms will have large spikes due to the peaks of arterial blood pressure whereas venous waveforms appear typically as plateaus of Doppler flow. Applying Doppler and checking for both venous and arterial flow can further demonstrate the severity of the torsion.  The same technique will be employed on the affected testicle. 

Assessment for pyuria with urineanalysis is typically part of the acute scrotal pain workup. The presence of pyuria is consistent with epididymitis, orchitis, or urinary tract infection but does not rule out the possibility of testicular torsion. [6][7]

Treatment / Management

Ultrasound is not a perfect test for testicular torsion, especially in the very young. For example, 40% of neonatal testicles may have no apparent color flow doppler. If the clinical concern is high, seek urologic surgery consultation immediately. Any delay in treatment could result in testicular necrosis and loss. The typical window of opportunity for surgical intervention and testicular salvage is 6 hours from onset of pain. Therefore, early urologic surgery consultation upon presentation may be critical even in the absence of confirmatory testing. 

Manual detorsion should be attempted if urological intervention is not immediately available. The abnormal testicle should be rotated in a medial to lateral direction (open book) 180 degrees and then evaluated for pain relief. If the pain is increased, consider rotating the testicle in the opposite direction. Ultrasound also can be used serially to evaluate for return of blood flow at the bedside. If unsuccessful, further manual detorsion may be attempted as the testicle can twist 1080 degrees.[5][8][9]

Differential Diagnosis

  • Testis tumor
  • Epididymitis
  • Hydrocele
  • Traumatic hematoma
  • Orchitis

Complications

  • Loss of testis
  • Infection
  • Infertility
  • Cosmetic deformity

Pearls and Other Issues

Ultrasound is a sensitive and specific test for the evaluation of testicular torsion. Early urology involvement is crucial to avoid testicular loss. The use of color flow is essential in the evaluation of testicular torsion.  

Enhancing Healthcare Team Outcomes

Testicular torsion is a surgical emergency that almost always presents to the emergency department. The first person to encounter the patient is the triage nurse who must be familiar with the symptoms of the disorder. Time is of the essence and the nurse should quickly notify the ER physician, who should consult with a radiologist for the appropriate test. The urologist is usually required to perform the surgery. The nurse should educate the family and the patient about the potential complications, including loss of the testis and infertility. The nurse should ensure that the patient is administered no food or drink by mouth and have the patient prepared to go for urgent surgery. More important, the nurse should avoid giving any pain medications until the patient has been seen by the urologist- or the pain medication will mask the symptoms and delay the diagnosis. Only through a systemic approach to diagnosis and treatment, is salvage of the testis a possibility.[10][11] (Level V)

Outcomes

The outcomes of testicular torsion depend on when the patient presents to the ER and how quickly the diagnosis is made and treatment undertaken. Delays in diagnosis and treatment always lead to testicular atrophy. About 20-40% of cases of testicular torsion result in an orchiectomy. The risk of losing a testis is much higher among African Americans and younger males. For those who present within the first 6 hours of symptoms, the salvage rate is nearly 100% but this number quickly drops to less than 50% if the delay in seeking help is more than 12-24 hours. More important, when the testis is fixed by orchiopexy, there is also a potential for future torsion.[12][4] (Level V)


Attributed To: Contributed by Michael Schick DO, MA

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Testicular Torsion - Questions

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A male is kicked in the groin during a football game. On exam, when the testes are lifted, the pain is relieved. What is the next step?



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Which is false about torsion of the spermatic cord?



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Which of the following is not true of torsion of the spermatic cord?



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What can result from the bell clapper deformity?



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Testicular torsion is commonly observed in which age group?



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Which of the following about testicular torsion is TRUE?



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On physical examination, which of the following is usually seen in patients with testicular torsion?



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Which of the following is a cause of testicular torsion?



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Which of the following about testicular torsion is true?



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If you perform a manual detorsion of the testes, the process involves twisting the testes in what motion?



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Which of the following urological disorders requires the most emergent care?



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A 17-year-old presents with testicular pain. It started as low abdominal pain 4 hours ago at a backyard football game but now radiates to the testicle. The patient is not sexually active and had no direct trauma. Which of the following statements is correct about the management of this patient?



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Which of the following is not associated with testicular torsion?



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Which statement about testicular torsion is true?



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Testicular torsion is imaged with Doppler ultrasound. What finding is diagnostic for torsion?



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An 11-year-old male presents to the emergency room with severe scrotal pain present for four hours. Select the first step in management.



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A 17-year-old male presents with sudden onset of pain and swelling of the left testis. He admits to unprotected sex. Exam shows extreme tenderness and swelling of the left testes and absent cremasteric reflex. Elevation of the scrotum exacerbates the pain. What is the next step in management?



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A testicular scintigram delayed static images is being reviewed. If the is testicular torsion what be true of the activity in the right testicle?



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In a patient with testicular torsion, surgery should be done within what time period to salvage the testes?



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When evaluating for testicular torsion with ultrasound, is venous or arterial blood supply cut off first?



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What ultrasound transducer should be used during the evaluation of testicular torsion?



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Which of the following is the most accurate method for diagnosing testicular torsion?



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A nurse intern is working in the pediatric unit this week with their preceptor. As they enter the room of a 12-year-old male, the patient is lying in bed rocking back and forth and complaining of sudden left testicular pain that woke him up. The caregiver relates that the testis is swollen and dark in color. The caregiver also relates a positive family history of the same event happening in an older brother. The patient is nauseous and has 9/10 pain in the left testicle and lower abdomen. The male preceptor performs a detailed assessment and obtains vital signs. An absent cremasteric reflex is noted on the left side. The left testicle is edematous, dark in color, and is riding higher than the right testicle. The patient is afebrile with a respiratory rate of 22, heart rate 118 beats/min, blood pressure 140/70 mmHg, and pulse oximetry 100% on room air. How should the novice nurse and their preceptor proceed in the management of care for this patient? Select all that apply.



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Testicular Torsion - References

References

Monteilh C,Calixte R,Burjonrappa S, Controversies in the management of neonatal testicular torsion: A meta-analysis. Journal of pediatric surgery. 2018 Aug 8     [PubMed]
Osumah TS,Jimbo M,Granberg CF,Gargollo PC, Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes. Journal of pediatric urology. 2018 Jul 21     [PubMed]
Boniface MP,Mohseni M, Acute Pain, Scrotum null. 2018 Jan     [PubMed]
Naouar S,Braiek S,El Kamel R, Testicular torsion in undescended testis: A persistent challenge. Asian journal of urology. 2017 Apr     [PubMed]
Mellick LB,Sinex JE,Gibson RW,Mears K, A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatric emergency care. 2017 Sep 25     [PubMed]
Mellick LB,Al-Dhahir MA, Cremasteric Reflex null. 2018 Jan     [PubMed]
Bandarkar AN,Blask AR, Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatric radiology. 2018 May     [PubMed]
Friedman AA,Palmer LS,Maizels M,Bittman ME,Avarello JT, Pediatric acute scrotal pain: A guide to patient assessment and triage. Journal of pediatric urology. 2016 Apr     [PubMed]
Fantasia J,Aidlen J,Lathrop W,Ellsworth P, Undescended Testes: A Clinical and Surgical Review. Urologic nursing. 2015 May-Jun     [PubMed]
Tydeman C,Davenport K,Glancy D, Suspected testicular torsion - urological or general surgical emergency? Annals of the Royal College of Surgeons of England. 2010 Nov     [PubMed]
Murár E,Omaník P,Funáková M,Béder I,Horn F, [Acute scrotum is a condition requiring surgical intervention]. Rozhledy v chirurgii : mesicnik Ceskoslovenske chirurgicke spolecnosti. 2008 Oct     [PubMed]
Howe AS,Vasudevan V,Kongnyuy M,Rychik K,Thomas LA,Matuskova M,Friedman SC,Gitlin JS,Reda EF,Palmer LS, Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion. Translational andrology and urology. 2017 Dec     [PubMed]

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