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.

[Outline]

• DESCRIPTION
• EPIDEMIOLOGY
• ETIOLOGY

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

ALERT

Pediatric Considerations

• 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–Schönlein 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

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

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

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

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.

• 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.

ICD9

• 608.20 Torsion of testis, unspecified
• 608.21 Extravaginal torsion of spermatic cord
• 608.22 Intravaginal torsion of spermatic cord

ICD10

• N44.00 Torsion of testis, unspecified
• N44.01 Extravaginal torsion of spermatic cord
• N44.02 Intravaginal torsion of spermatic cord

[Outline]

• ICD9
• ICD10

• 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.
• Drlík M, Kovara 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

Edward Newton