Basics
Description
- Rotation of the testicle around the spermatic cord and vascular pedicle
- Rotation often occurs medially (two-thirds of cases):
- Ranges from incomplete (90 " 180 °) to complete (360 " 1,080 °) torsion
- Depending on the degree of torsion:
- Vascular occlusion occurs
- Infarction of the testicle after more than 6 hr of warm ischemia
- Testicular salvage:
- 73 " 100% with <6 hr of ischemia
- 50 " 70% at 6 " 12 hr
- <20% after 12 hr
- It is still worthwhile to attempt to salvage the testicle up to 24 hr after the onset.
- Testicular infarction leads to atrophy and may ultimately decrease fertility.
Epidemiology
Bimodal distribution of torsion:
- Peak incidences in infancy and adolescence
- 85% of cases occur between ages 12 and 18 yr, with a mean of 13 yr.
- Torsion is rare after age 30 but still possible.
Etiology
- Congenital abnormality of the genitalia:
- High insertion of the tunica vaginalis on the spermatic cord
- Redundant mesorchium
- Permits increased mobility and twisting of the testicle on its vascular pedicle
- The anatomic abnormality is bilateral in 12%, so both testicles are susceptible to torsion.
Diagnosis
Signs and Symptoms
History
- Sudden onset of unilateral testicular pain
- Scrotal swelling and erythema
- Less commonly, torsion may present with pain in the inguinal or lower abdominal area.
- Up to 40% of patients may describe previous similar episodes that remitted spontaneously:
- Represents spontaneous torsion and detorsion
- Nausea and vomiting occur in 50% of cases.
- Low-grade fever occurs in 25%.
- There is often a history of minor trauma to the testicle preceding the onset of pain.
- Symptoms of urinary infection (dysuria, frequency, and urgency) are absent.
Physical Exam
- In distinguishing torsion from epididymitis, localized tenderness is helpful early; however, once significant scrotal swelling occurs, the anatomy becomes indistinct.
- Torsion of the appendix testis is less painful and does not threaten the viability of the testicle
- Characterized by the "blue dot " sign
- The affected torsed testicle may lie transversely as opposed to the normal vertical lie.
- Cremasteric reflex is frequently absent on the affected side with testicular torsion.
- Sensitivity 96%; specificity 66%
- Prehn sign:
- Relief of pain on elevation of the testicle in epididymitis
- Worsening or no change in the pain with torsion
- Considered unreliable
Essential Workup
- The presentation of an "acute scrotum " in a child or adolescent requires rapid assessment and immediate consultation with a urologist.
- These patients require noninvasive flow studies or surgical exploration to confirm torsion.
- 3.3 (ED) " 30% (Urology service) of these patients ultimately prove to have testicular torsion.
Diagnosis Tests & Interpretation
Lab
- Elevated WBC count with a left shift is present in 50% of cases.
- Urinalysis is usually normal, but up to 20% of cases of torsion include pyuria.
- There are no lab tests specific for testicular torsion.
Imaging
- There are limitations of all flow studies:
- Reflect only the current state of perfusion
- Spontaneously detorsed testicle may show normal or even increased flow.
- Still at high risk for recurrent torsion
- Traditional criterion standard has been technetium-99m radionuclide scans:
- Decreased flow in the torsed testicle compared with the unaffected side
- Frequent time delays in obtaining scans
- Doppler ultrasound:
- Assess testicular blood flow and visualize the torsed spermatic cord directly.
- Has replaced nuclear scanning:
- Less invasive
- More readily available test
- Comparable results
- Overall sensitivity and specificity of 98% and 100%, respectively for torsion but lower in distinguishing between testicular torsion and torsion of the appendix testis.
- Epididymitis will reveal increased flow due to inflammation.
- Torsion will reveal decreased or no blood flow.
- Color-flow Doppler is most commonly available.
- Use of Doppler contrast material may enhance the accuracy.
- High definition ultrasound (HDUS) is emerging as an accurate means of directly imaging the torsed spermatic cord
- All imaging techniques have technical limitations in infants:
- Testicular vessels are very small.
- Amount of blood flow to the testicle under normal conditions is minimal.
- Scrotal exploration may be required.
Diagnostic Procedures/Surgery
- Scrotal exploration can be done rapidly under local anesthesia to diagnose and treat torsion.
- The "bell-clapper " deformity of both testicles should be corrected by orchiopexy.
Differential Diagnosis
- Acute hydrocele
- Epididymitis/orchitis
- Henoch " Sch Άnlein purpura
- Incarcerated inguinal hernia
- Testicular neoplasm
- Testicular trauma or rupture of the testicle
- Torsion of the appendix testis (31 " 70% of acute scrotum cases)
- Other intra-abdominal conditions:
- Appendicitis
- Pancreatitis
- Renal colic
Treatment
Pre-Hospital
- There is no definitive treatment that can be rendered in the field.
- Pre-hospital personnel must recognize the urgency of acute testicular pain in young patients.
- These patients should be transported to the ED immediately.
Initial Stabilization/Therapy
IV fluid, analgesics as appropriate
Ed Treatment/Procedures
- Rapid triage and assessment
- Exam of testicle to exclude primary neoplasm
- Establish the diagnosis and mobilize appropriate urologic care.
- Applying an ice pack to the scrotum relieves pain:
- May prolong the viability of the ischemic testicle
- If definitive care is likely to be delayed beyond 4 " 5 hr from the onset of torsion, manual detorsion may be attempted (26.5 " 80% successful).
- Externally rotate the affected testicle opposite the usual medial direction of torsion.
- Continue until pain is relieved, normal anatomy is restored, or Doppler US shows return of flow.
- All patients who undergo manual detorsion must be surgically explored.
Medication
Analgesia
Follow-Up
Disposition
Admission Criteria
- Patients with confirmed torsion must be admitted for scrotal exploration and bilateral orchiopexy.
- Flow studies that are inconclusive and technical failures mandate further investigation by surgical exploration of the scrotum.
- Admission for urgent surgical exploration of an acute scrotum is mandatory if there is any potential delay in obtaining a flow study:
- Patients in whom apparent spontaneous detorsion has occurred should undergo elective exploration for bilateral orchiopexy.
Discharge Criteria
- Patients with negative scrotal exploration and those with normal flow studies can be discharged with appropriate urologic follow-up.
- Parameters for return to ED must be discussed because of the possibility of recurrent torsion.
- Patients with an obvious diagnosis other than testicular torsion can be referred for care.
Pearls and Pitfalls
- Testicular torsion can mimic acute appendicitis in children.
- Remember that "time is testicle " ; emergent workup and consultation are required.
- Maintain a high index of suspicion for testicular torsion in all age groups even though peak incidence is in adolescents and neonates.
- If testicular torsion is diagnosed early, a near 100% salvage rate for the testicle is possible. Orchiopexy is not a guarantee against future torsion, although it does reduce the odds.
Additional Reading
- Baldisserotto M. Scrotal emergencies. Pediatr Radiol. 2009;39:516 " 521.
- Beni-Israel T, Goldman M, Chaim S, et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. 2010;28:786 " 789.
- Drl k M, Ko vara R. Torsion of spermatic cord in children: A review. J Pediatr Urol. 2013;9:259 " 266.
- Gatti JM, Murphy JP. Acute testicular disorders. Pediatr Rev. 2008;29:235 " 241.
- Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion? J Fam Pract. 2009;58:433 " 434.
See Also (Topic, Algorithm, Electronic Media Element)
- Epididymitis/Orchitis
- Hydrocele
Codes
ICD9
- 608.20 Torsion of testis, unspecified
- 608.21 Extravaginal torsion of spermatic cord
- 608.22 Intravaginal torsion of spermatic cord
- 608.23 Torsion of appendix testis
- 608.24 Torsion of appendix epididymis
- 608.2 Torsion of testis
ICD10
- N44.00 Torsion of testis, unspecified
- N44.01 Extravaginal torsion of spermatic cord
- N44.02 Intravaginal torsion of spermatic cord
- N44.03 Torsion of appendix testis
- N44.04 Torsion of appendix epididymis
- N44.0 Torsion of testis
SNOMED
- 81996005 Torsion of testis (disorder)
- 198047009 Torsion of appendix of testis (disorder)
- 304544003 Intermittent torsion of testis (disorder)