Testicular torsion

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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)
  • Half occur during sleep
  • Bimodal incidence
    • First peak in first year of life
    • Second peak at puberty

Risk factors

  • 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
  • Physical exam:
    • Swollen, high-riding testis
    • Transverse testicular lie
    • Absent cremasteric reflex on affected side (99% sensitivity)

Differential Diagnosis

Testicular Diagnoses

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[1]
  • 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)[2]
  • 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)
  • Urological consultation for detorsion and orchipexy

Manual Detorsion

  • Not definitive treatment
    • Temporizing measure if urologist not immediately available
  1. Provide parenteral analgesia or perform cord block (grasp cord at external ring and inject 10 mL lidocaine directly into 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

Disposition

  • To OR or urology

See Also

References

  1. Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.
  2. Barbosa, JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.