Testicular torsion

Background

Scrotal anatomy

Testicular anatomy

1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)

• Must consider as a ddx in all acute scrotal pain
  • May lead to testicular ischemia and subsequent infertility
• A clear precipitating factor is not necessary identified; half occur during sleep
• Bimodal incidence
  • First peak in first year of life
  • Second peak at puberty

Risk factors

• Mechanical: Exertional/exercise, trauma
• Testicular masses
• Undescended testicle
• Bell-clapper deformity

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 or vomiting
  • May have previous similar intermittent, self-resolving episodes
  • May present after scrotal trauma with persistent pain
  • May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain
• Physical exam:
  • Swollen, tender, high-riding testis
  • Transverse testicular lie
  • Absent cremasteric reflex on affected side (99% sensitivity)

Differential Diagnosis

Testicular Diagnoses

• Scrotal cellulitis
• Epididymitis
• Fournier gangrene
• Hematocele
• Hydrocele
  • Hydrocele (peds)
• Indirect inguinal hernia
• Inguinal lymph node (Lymphadenitis)
• Orchitis
• Scrotal abscess
• Spermatocele
• Tinea cruris
• Testicular rupture
• Testicular torsion
• Testicular trauma
• Testicular tumor
• Torsion of testicular appendage
• Varicocele
• Pyocele
• Testicular malignancy
• Scrotal wall hematoma

Evaluation

Work-Up

• Do not delay urologic consultation for work-up
  • Consult urology immediately if strongly suspicious for torsion
• Urinalysis
• Ultrasound for equivocal cases
  • Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S
• 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)
• Scores from 2-5 patients require U/S for further assessment

Diagnosis

• Ultrasound
  • Only indicated for equivocal cases
  • Unilateral absence of blood flow

Management

• Manual detorsion (temporizing measure)
  • Typically done if surgical management is not immediately available
• Urological consultation for detorsion and orchipexy
  • Surgical exploration is the gold standard; without surgery, difficult to determine if manual detorsion has worked

Manual Detorsion

• Not definitive treatment. Temporizing measure if urologist not immediately available
• May require conscious sedation or parenteral analgesia if severe pain is anticipated

1. May perform cord block
   • Grasp spermatic cord as it enters scrotum, track up to external ring, create skin wheal, and inject 10 mL lidocaine directly into the anterior, lateral, medial portions of cord
2. "Open the book" by twisting testicle outward and laterally
   • Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
3. Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases
4. If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
   • In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed

Disposition

• To OR or urology

See Also

• Testicular diagnoses
• Testicular ultrasound