Hospital Medicine

Testicular torsion

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Testicular Torsion

I. What every physician needs to know.

Testicular torsion is considered a clinical emergency. It occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. Without intervention, the testes becomes ischemic with eventual testicular loss.

Approximately 90% of torsion is due to the anatomic "bellclapper" defect in which there is abnormal fixation of the testes within the tunica vaginalis allowing for increased mobility.

II. Diagnostic Confirmation: Are you sure your patient has Testicular Torsion?

Based on history and physical exam, most clinicians can make an accurate diagnosis of testicular torsion.

A. History Part I: Pattern Recognition:

Males with testicular torsion present acutely with severe scrotal pain usually within less than 6 hours and usually no more than 24 hours of symptoms. There may be a history of vigorous physical activity or minor trauma prior to the onset of pain. The past medical history may be significant for undescended testes. The scrotal pain is usually unilateral. However, because of the anatomy, the other testes should always be evaluated. There may also be associated nausea and vomiting.

The finding of 2 out of 3 of the following was associated with higher likelihood of torsion: pain less than 24 hours, nausea and/or vomiting, abnormal (high riding) testicular orientation.

Physicians must have a high index of suspicion in adolescent males who complain of lower abdominal pain.

Intermittent testicular torsion presents with multiple episodes of acute scrotal pain with spontaneous resolution.

Fever, dysuria, or penile discharge should prompt investigation for an infectious etiology. Urinary frequency is uncommon and may suggest epididymitis or orchitis.

B. History Part 2: Prevalence:

Testicular torsion occurs most commonly in males ages younger than 25 years and is most common during prepuberty (ages 12 years to 18 years) with peak age of incidence of 14 years old. A smaller incidence occurs in the first week of life of the neonatal period. There is a higher incidence of testicular torsion in infants with cryptorchidism. Testicular torsion does not generally affect the elderly. Testicular torsion appears to be more common in the winter months, especially December and January. A genetic or familial etiology is uncommon.

C. History Part 3: Competing diagnoses that can mimic Testicular Torsion.

It is important for the clinician to be aware of the other causes of acute scrotal pain.

Epididymitis is defined as inflammation of the epididymis. It can present as acute scrotal pain and scrotal erythema. It is most common in the prepubescent and sexually active males.

Trauma from a variety of causes can present as acute scrotal pain. Injuries range from a hematocele to testicular rupture.

Torsion of the Appendix Testis presents as a sudden onset of scrotal pain with tenderness located to the superior pole of the testes. Onset is usually more gradual than that seen with testicular torsion. On exam, the clinician may note a "blue dot: sign" caused by infarction and necrosis.

Intermittent Testicular Torsion presents with multiple episodes of acute scrotal pain with spontaneous resolution. This usually occurs at night during REM sleep and is thought to be due to contraction of the cremaster muscles. A horizontal testicle is highly suggestive of torsion.

D. Physical Examination Findings.

The clinician may observe abnormal testicular orientation with the affected testes high-riding and oriented transversely. There is also noted diffusely tender swollen testes or epididymal tenderness. Scrotal swelling and erythema and reactive hydrocele may also be present in delayed presentations.

Decrease or absence of cremasteric reflex is the most sensitive sign (approaching near 100%). In normal males, the cremasteric reflex is elicited by stroking or pinching the medial thigh. This causes the cremaster muscle to contract and the testicle will elevate at least 0.5cm. In males with testicular torsion, this reflex is absent.

The Prehn sign, in which the examiner elevates the scrotal contents and relief of pain suggests epididymitis and no relief of pain or aggravation of pain suggests testicular torsion, has not been shown to be a reliable feature.

E. What diagnostic tests should be performed?

Neither ultrasound nor testicular scintigraphy are superior in the diagnosis of testicular torsion. There are limitations to the studies and it can be difficult to differentiate torsion from epididymitis. However, due to radiation concerns in children, ultrasound is usually preferred.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

A urinalysis is sometimes obtained to access for pyuria or bacturia which would suggest an infectious etiology. CBC and CRP may suggest epididymitis or orchitis, Fournier gangrene or scrotal abscess, but is unnecessary in the workup of testicular torsion.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Color Doppler ultrasound has been shown to be specific but not sensitive in the evaluation of testicular torsion. Ultrasound relies on the findings of absence of blood flow for the diagnosis of testicular torsion. However, in some cases of testicular torsion, there may be preserved blood flow. Ultrasound cannot reliably distinguish torsion of the appendix from epididymitis and in fact may overdiagnose epididymitis. Normal or increased testicular blood flow may suggest detorsion or an inflammatory process. Power Doppler is more sensitive than regular color Doppler to pick up the presence of blood flow. High resolution ultrasound findings of the spermatic cord showing twisting increases the likelihood of testicular torsion.

Testicular Scintigraphy or Radionuclide Scrotal imaging using technitium Tc99m is limited since it cannot distinguish torsion of appendix from early torsion of the testes. It is more sensitive that color doppler but takes longer and is not always readily available. The anatomy and vascular perfusion obtained can help distinguish testicular torsion from nonsurgical causes of acute scrotum.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

CBC, CRP and urinalysis are normal and are not necessary to obtain in cases where there is a high index of suspicion for testicular torsion. However, they are reasonable to obtain to rule out a genitourinary infection, since this is often in the differential diagnosis.

III. Default Management.

If the history and physical exam suggest testicular torsion, initial consultation with a specialist (Urology, Pediatric surgery) should be done without delay. Radiology studies may be ordered or in some instances expedited surgical exploration is performed.

Surgery is the definitive treatment if torsion is present and consists of detorsion and fixation (orchiopexy) of not only the involved testis but also the contralateral uninvolved testis.

Patients with a history of undescended testes and those with a bell-clapper deformity should be referred for repair.

Patients with intermittent episodes of testicular pain that spontaneously resolve (i.e. intermittent testicular torsion), should be referred for urological evaluation.

A. Immediate management.

It is unknown how long a testicle can remain torsed and still regain function. The usual times quoted range from 6 hours to 24 hours with irreversible damage usually occurring after 12 hours. However, surgery should be done as quickly as possible to assure testicular salvage.

Even if a study is negative, if there is still clinical suspicion, consultation and emergency surgical exploration should immediately proceed. Further testing may simply delay the diagnosis and delay surgical intervention that is needed.

Surgery consists of detorsion and fixation of both the involved testis and the contralateral testis (orchiopexy).

Orchiectomy is reserved if the testis is nonviable.

Surgery involving testicular fasciotomy along with a tunica vaginalis patch which relieves the testicular compartment pressure may lead to improved testicular tissue viability.

In the event that there is no surgeon or urologist available, and the suspicion for torsion is high, manual detorsion is indicated. The bedside procedure involves positioning in front of the patient and usually twisting the testes in an outward and laterally direction. Manual detorsion is not without complications including severe pain, incomplete or failure to detorse, or worsening of the torsion. Concomitant use of bedside ultrasound with manual detorsion can improve the outcome. Relief of pain following the maneuver as well as normal orientation in the scrotum, indicates successful detorsion. Ultrasound confirmation of blood flow restoration is confirmatory. However, manual detorsion is not a replacement for surgery and is performed only until definitive surgical intervention can occur.

Adequate analgesia and sedation should be provided to improve patient cooperativity with diagnostic tests and manual detorsion.

Antiemetics may be given for patients who experience nausea or vomiting.

B. Physical Examination Tips to Guide Management.

Post-operative complications include infection.

Delayed complications such as testicular atrophy, decreased spermatogenesis, and infertility may occur especially if there is delay between diagnosis and definitive repair.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

None

D. Long-term management.

Many years later, some patients who have undergone testicular fixation may develop recurrent torsion. The type of suture material (absorbable or nonabsorbable) does not seem to be a factor.

Patients should be informed of the possibility of recurrent testicular torsion and the need to obtain immediate urologic evaluation if they should experience sudden testicular pain.

For patients who have to undergo orchiectomy, a saline implant prosthetic device may help the cosmetic appearance as well as improve the persons' psychological well-being. Testosterone releasing prosthetic devices have been investigated.

Hormonal treatment after orchiectomy may be needed in a prepubertal boy in order to improve the likelihood of appropriate pubertal development.

E. Common Pitfalls and Side-Effects of Management.

The general approach to a prepubertal male with high index of suspicion for testicular torsion involves:

  • Immediate urologic consultation for emergency exploration plus supportive care, OR

  • If immediate surgical consultation is unavailable for several hours, manual detorsion followed by scrotal exploration plus supportive care.

Common pitfalls include failure to recognize testicular torsion and delay in obtaining urologic consultation, misdiagnosing testicular torsion as epididymitis, and incomplete reduction of a torsion by manual detorsion. This leads to complications such as infarction of the testicle, permanent testicular damage, and loss of the testicle.

Surgery risks may be due to the anesthesia and consists of allergic reaction to medication and breathing problems. Other surgical risk factors include infection and bleeding.

Pain Medication:

-Acetaminophen (Tylenol)

*adults--650 mg orally every 4 to 6 hours if needed

*children--10-15mg/kg/dose every 4 to 6 hours if needed

-Ibuprofen (Advil or Motrin) 400mg to 600mg orally every 8 hours if needed

-Morphine sulfate

*adults--0.1mg/kg (usually 5-10 mg) IV/IM/SC every 4 hours; titrating if needed

*children--0.1 to 0.2 mg/kg/dose IV/IM every 4 hours if needed

-Ondansetron (zofran)

*adults--4 mg IV/po every 4 to 6 hours if needed for nausea or vomiting

*children--ages 6months to 18 years--0.15mg/kg IV every 4 to 6 hours if needed for nausea or vomiting. 2-4mg po every 4 to 6 hours if needed

-Diazepam

*adults--2-10mg po/IV/IM every 3 to 4 hours if needed for anxiety; maximum 30 mg every 8 hours

*children--0.12 to 0.8 mg/kg po every 6-8 hours if needed for anxiety; maximum 10mg per dose

IV. Management with Co-Morbidities.

Since the majority of cases presenting as testicular torsion are young adult males, no change in standard management is needed.

A. Renal Insufficiency.

Rarely, testicular torsion may be seen after kidney transplantation. It is unclear whether this is coincidental or if it is a direct consequence of kidney transplantation.

B. Liver Insufficiency.

No known association.

C. Systolic and Diastolic Heart Failure.

No known association.

D. Coronary Artery Disease or Peripheral Vascular Disease.

No known association.

E. Diabetes or other Endocrine issues.

Testicular torsion may be cause of infertility later in life. However, this does not seem to be influenced by the type of surgery (i.e. orchiopexy versus orchidectomy). Hormonal treatment may be needed. In most instances, if one testes has been removed, the remaining healthy testes should produce enough hormones.

F. Malignancy.

Testicular torsion is not associated with testicular cancer. However, children with a history of undescended testes who have undergone orchiopexy after the age or 11 years have an increased risk of testicular cancer.

G. Immunosuppression (HIV, chronic steroids, etc).

No known association.

H. Primary Lung Disease (COPD, Asthma, ILD).

No known association.

I. Gastrointestinal or Nutrition Issues.

No known association.

J. Hematologic or Coagulation Issues.

No known association.

K. Dementia or Psychiatric Illness/Treatment.

There can be psychological implications in men after losing a testis. Implant prosthetic devices may be useful.

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

Usually same day discharge after surgery. Monitor for any signs of postoperative infection. Keep the dressing dry and remove after 48 hours.

Scrotal postoperative swelling may last for 2 to 3 weeks. Ice packs, scrotal elevation for 1 week using an athletic support or scrotal support are useful adjuncts to reduce the swelling.

Pain medication if needed.

B. Anticipated Length of Stay.

Usually same day discharge after surgery or less than 24 hours observation.

C. When is the Patient Ready for Discharge?

Criteria for discharge include afebrile vital signs and adequate analgesia.

D. Arranging for Clinic Follow-up.

Avoid strenuous activity for 1 to 2 weeks and avoid sexual activity for 4 to 6 weeks. Normal activity may be resumed after a few weeks. Follow-up with urologic specialist annually.

1. When should clinic follow up be arranged and with whom?

A follow-up appointment with Surgery is generally recommended after 10-14 days for a wound check.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

Annual scrotal ultrasound during the first 2 to 3 years after surgery can be done to document testicular volume and growth. However, most patients do not return for follow-up.

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

N/A

E. Placement Considerations.

Discharge plans are to home.

F. Prognosis and Patient Counseling.

There can be psychological issues which occur with losing a testicle. Not only is there the cosmetic deformity but also the concerns of infertility. Saline implant prosthetic device may be helpful.

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

Documentation of testicular torsion and immediate referral to urologic specialist.

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Patients should be informed of the possibility of recurrent testicular torsion and the need to obtain immediate urologic evaluation if they should experience sudden testicular pain.

VII. What's the evidence?

Yin, S, Trainor, JL. "Diagnosis and Management of Testicular Torsion, Torsion of the Appendix Testis, and Epididymitis. Clin Ped Emer". Med. vol. 10. 2009. pp. 38-44.

Dogra, V, Bhatt, S. "Acute Painful Scrotum". Radiol Clin North Am. vol. 42. 2004. pp. 349-63.

Boettcher, M, Bergholz, R, Kreb, TF, Wenke, K, Aronson, DC. "Clinical Predictors of testicular torsion in children". Urology. vol. 79. 2012. pp. 670-674.

Lindsey, D, Stanisic, TH. "Diagnosis and Management of Testicular Torsion: Pitfalls and Perils". Am J Emerg Med. vol. 6. 1988. pp. 42-46.

Cummings, JM, Boullier, JA, Sekhon, D, Bose, K. "Adult testicular torsion. ". Urol. vol. 167. 2002. pp. 2109-2011.

Nussbaum Blask, AR, Bulas, D, Shalaby-Rana, E, Rushton, G, Shao, C, Majd, M. "Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain. Pediatr Emer". Care.. vol. 18. 2002. pp. 67-71.

Marcozzi, D, Suner, S. "The nontraumatic acute scrotum. Emerg Med Clin Nort". Am. vol. 19. 2001. pp. 547-550.

Ringdahl, E, Teague, L. "Testicular Torsion". Am Fam Physician. vol. 74. 2006. pp. 1739-1743.

Livne, PM, Sivan, B, Karmazyn, B. "Testicular torsion in the pediatric age group: diagnosis and treatment". Pediatr Endocrinol Rev. vol. 2. 2003. pp. 128-33.

Kadish, Ha, Bolte, RG. "A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages". Pediatrics. vol. 102. 1998. pp. 73-6.

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