REBEL Core Cast 91.0 – Testicular Torsion

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Definition: Twisting of the spermatic cord leading to decreased blood flow to the testicle resulting in ischemia, infarction and potentially, tissue necrosis.

Epidemiology:

• Most common cause of acute scrotal pain in prepubertal boys
• Torsion present in 3.2% of all children presenting to the ED with scrotal pain (Ben-Israel 2010 )
• Bimodal frequency: peaks in 1st year of life and again at puberty
• Risk factors: History of cryptorchidism, horizontal testicular lie, increased spermatic cord length

Pathophysiology:

• Anatomical defect in the tunica vaginalis allowing the testicle to rotate when the cremasteric muscle contracts
• Twisting of the testicle initially causes compromised venous return and can lead to arterial obstruction, ischemia and tissue necrosis
• Testicle can rotate from 180^o to 720^o
• Longer duration of torsion increases the risk of tissue necrosis

Differential Diagnosis

• Hydrocele
• Epididymitis
• Epididymorchitis
• Trauma
• Inguinal hernia
• Testicular tumor

Clinical Presentation

“No discriminating features in either history or examination conclusively differentiate the correct diagnosis” (Sidler 1997 )

History

• Sudden onset of scrotal pain (less frequently, abdominal or inguinal pain)
• Nausea and vomiting
• History of blunt trauma (~ 10% of patients)
• History of similar pain in the past
• Up to 20% of patients will have abdominal or flank pain alone (Mellick 2012 )
• Presentation is often delayed (mean time to presentation 9.5 hours) (Rosen’s)
• Duration of symptoms should NOT guide management
  • Historically, believed that symptoms > 24 hours inconsistent with salvageable tissue
  • However, testicle may torse + detorse making it difficult to know how long ischemia present.
• Systematic review by Mellick demonstrates significant survival rates past 48 hours (Mellick 2019).
  • Survival < 6 hours: 97%
  • Survival 7-12 hours: 79%
  • Survival 13-18 hours: 61%
  • Survival 19-24 hours: 24%
  • Survival 25-48 hours: 7.4%

Physical Examination

• No single examination finding rules in or out the diagnosis of testicular torsion
• Unilateral tender, firm testicle
• Scrotal erythema, edema and swelling
• Affected testicle typically higher than the unaffected one. OR = 58.8 (Ben-Israel 2010)
• Loss of cremasteric reflex
  • Previously thought to be 100% sensitive and highly specific
  • 30% of males with normal testicles will have an absent cremasteric reflex
  • Studies report varying sensitivities as low as 60% (Mellick 2012 )
• Horizontal (instead of vertical) testicular lie

Diagnosis

• The diagnosis of testicular torsion should be pursued in any patient with acute scrotal pain. Physical exam, history and imaging all have significant limitations.
• In patients with a high suspicion for torsion, emergent surgical consultation should not be delayed by diagnostic imaging as “time is testicle”
• Scrotal Ultrasound
  • Standard imaging technique
  • Diagnostic characteristics
    • Sensitivity: 88 – 100% (+ Lr = 8.8 – 10)
    • Specificity: 90%
    • (+) LR = 8.8-10, (-) LR = 0.13
  • Findings
    • A torsed testicle will be hypoechoic, heterogeneous and enlarged
    • Color doppler will demonstrate decreased or absent blood flow
    • A partially-torsed testicle may have arterial flow but no venous flow, or may show an abnormal high-resistance pattern of arterial flow
    • A testicle that has recently de-torsed will appear enlarged and hyperemic
  • Due to the relatively low sensitivity, a negative color doppler ultrasound does not always rule out the disease
  • Examination of the spermatic cord for twisting increases the false negative rate improving the utility of ultrasound to rule out the diagnosis

Management:

• ALL patients with suspicion for testicular torsion should have immediate consultation with a urologist for potential operative exploration and repair.
• Establish IV access and provide analgesia
• Manual detorsion
  • Can be attempted if urology consultation is not immediately available
  • May be successful in 25-80% of testicular torsion cases (Rosen’s 2014)
  • Procedure
    • Place patient supine
    • Provider stands at the patients feet
    • Apply “open book” rotation: rotate affected testicle away from midline
    • Rotation required may be anywhere from 180^o – 720^o
  • Up to 1/3 of patients will be torsed in the “opposite” direction (Mellick 2012 )
  • Regardless of the success of manual detorsion, all patients will require surgical evaluation

Take Home Points

• Consider the diagnosis of testicular torsion in all patients with acute testicular pain
• Testicular torsion is a surgical emergency that requires immediate urologic consultation to increase the rate of tissue salvage.
• History, physical examination and ultrasound are all flawed in making the diagnosis. The gold standard is surgical exploration.
• Perform manual detorsion after diagnosis

Read More:

Video: The New Testicular Torsion Traction Technique

Ben-Israel T et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28:786-789. PMID: 20837255

Sidler D et al. A 25-year review of the acute scrotum in children. S Afr Med J. 1997;87(12) 1696-8. PMID: 9497837

Mellick LB. Torsion of the testicle: It is time to stopping tossing the dice. Pediatric Emer Care 2012; 28: 80-6. PMID: 22217895

Ban KM, Easter JS: Selected Urologic Problems; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 99: p 1326-1356.

Mellick LB et al. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-82

References:

Price DP. Chapter 127. Methemoglobin Inducers. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 9e New York, NY: McGraw-Hill; 2011.. Link

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)