Testicular Torsion

Background

• Testicular torsion is caused by twisting of the spermatic cord resulting in obstruction of testicular venous return, which may lead to compromised arterial flow and testicular ischemia.
• Testicular torsion is a surgical emergency.
• Torsion of the testis has bimodal distribution with a first age peak in the neonatal period and a second peak around puberty.
• The most common age at presentation is 12-18 years, with a peak between ages 13 and 14 years.
• Patients other than newborns usually present with a sudden onset of unilateral scrotal pain that is unrelenting, often with associated nausea and vomiting.
• Newborns may present with a hemiscrotal mass that is blue, firm, and nontender or with a more classic presentation of erythema and tenderness.

Evaluation

• Base clinical diagnosis of testicular torsion primarily on history and physical exam (Strong recommendation).
• If torsion is suspected, a Doppler ultrasound is the preferred imaging modality and is useful to evaluate for testicular torsion. Imaging should not delay surgical exploration (Strong recommendation).
• A relative decrease or absent arterial blood flow within the suspected testis on a color-flow Doppler ultrasound is indicative of testicular torsion.
• The diagnosis is confirmed at the time of surgical exploration.
• Exclude other causes of acute scrotal pain including epididymitis and torsion of the appendix testis or appendix epididymis.

Management

• Testicular torsion is a urological emergency which requires immediate treatment (Strong recommendation).
  • Early surgical intervention with detorsion may preserve testis function and fertility.
  • The time window for testis salvage following torsion is typically 4-8 hours (and up to 12 hours) before permanent ischemic damage occurs.
• Perform urgent surgical exploration in all patients with testicular torsion within 24 hours of the symptom onset (Strong recommendation).
• Surgical exploration should include:
  • detorsion of the affected spermatic cord
  • orchiopexy of the contralateral testicle
  • an assessment of testicular viability of the affected testicle
  • orchiopexy or orchiectomy on the affected testicle, depending on viability
• In newborns, acute scrotum should be considered a surgical emergency.
  • Determine timing of surgery based on clinical findings (Strong recommendation).
  • Consider performing orchidopexy of the contralateral testicle (Weak recommendation).
• Manual detorsion can reduce the severity of testicular torsion but should not supersede, delay, or replace surgical intervention.
• Manage torsion of appendix testis conservatively, but offer surgical exploration in unclear cases and in patients with persistent pain (Strong recommendation).