Testicular Torsion: Diagnosis, Evaluation, and Management

VICTORIA J. SHARP, Md, MBA, and KATHLEEN KIERAN, MD, University of Iowa Carver Higher of Medicine, Iowa City, Iowa

Am Fam Physician. 2013 Dec 15;88(12):835-840.

Patient information: Come across related handout on testicular torsion, written by the authors of this article.

This clinical content conforms to AAFP criteria for continuing medical pedagogy (CME). See CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Commodity Sections

  • Abstract
  • Historic period Distribution
  • Differential Diagnosis
  • Physical Test
  • Imaging
  • Management
  • References

Testicular torsion is a twisting of the spermatic cord and its contents and is a surgical emergency affecting 3.8 per 100,000 males younger than eighteen years annually. It accounts for 10% to 15% of acute scrotal disease in children, and results in an orchiectomy charge per unit of 42% in boys undergoing surgery for testicular torsion. Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum. Testicular torsion is a clinical diagnosis, and patients typically present with astringent astute unilateral scrotal pain, nausea, and vomiting. Physical examination may reveal a high-riding testicle with an absent-minded cremasteric reflex. If history and physical test suggest torsion, immediate surgical exploration is indicated and should not be postponed to perform imaging studies. There is typically a four- to eight-hr window before permanent ischemic damage occurs. Delay in treatment may exist associated with decreased fertility, or may necessitate orchiectomy.

A good working knowledge of testicular and scrotal anatomy and development is important when assessing a patient who presents with a scrotal status, considering time from presentation to treatment is crucial in preserving organ function.i–iv The testes develop from condensations of tissue inside the urogenital ridge at approximately vi weeks of gestation. With longitudinal growth of the embryo, and through endocrine and paracrine signals, which accept not even so been well described, the testes ultimately descend into the scrotum by the third trimester of pregnancy. As the testes leave the abdomen, the peritoneal lining covers them, creating the processus vaginalis. The spermatic arteries and pampiniform venous plexus enter the inguinal culvert proximal to the testes, and with the vas deferens, class the spermatic cord.5 The testicle is tethered to the scrotum distally by the gubernaculum.

Testicular torsion is a twisting of the spermatic cord and its contents and is a surgical emergency, with an annual incidence of 3.eight per 100,000 males younger than xviii years.6 Historically, the annual incidence has been closer to one per four,000.7 It accounts for approximately 10% to 15% of acute scrotal illness in children, and results in an orchiectomy rate of 42% in boys undergoing surgery for testicular torsion.6,8,9

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Scrotal Doppler ultrasonography is the imaging study of pick to aid in the diagnosis of testicular torsion; however, prompt referral should not exist delayed to perform this report.

C

25, 38–40

Immediate surgery should be performed if testicular torsion is suspected, and should non be delayed by imaging studies if concrete examination findings are strongly suggestive.

C

16, 17, 34

Manual detorsion should be attempted if surgery is not an immediate option; withal, prompt referral should not be delayed to perform this maneuver.

C

48, 49

Age Distribution

  • Abstract
  • Age Distribution
  • Differential Diagnosis
  • Concrete Exam
  • Imaging
  • Management
  • References

The age distribution of testicular torsion is bimodal, with 1 peak in the neonatal period and the second peak effectually puberty. In neonates, extravaginal torsion predominates, with the entire cord, including the processus vaginalis, twisting.10 Extravaginal torsion may occur antenatally or in the early postnatal period and typically presents equally painless scrotal swelling, with or without astute inflammation. Testicular viability in neonatal torsion is universally poor; one literature review of xviii case series with 284 patients found a save rate of about ix%.eleven Contralateral orchiopexy has been recommended at the time of surgical exploration considering the etiology for extravaginal torsion remains unclear.12 Although no specific take chances factors have been identified, poorer fixation of the neonatal tissues to one another has been implicated, and term infants with difficult or prolonged deliveries may exist at college risk.x

In older children and adults, testicular torsion is usually intravaginal (twisting of the cord within the tunica vaginalis).13 The bell-clapper deformity (Figure 1), in which there is abnormal fixation of the tunica vaginalis to the testicle, results in increased mobility of the testicle within the tunica vaginalis.14 Whether testicular torsion is intravaginal or extravaginal, twisting of the spermatic cord initially increases venous pressure and congestion, with subsequent subtract in arterial claret menstruum and ischemia.15 Although symptoms are typically unilateral, the anatomic weather that predispose a persion to torsion must exist presumed to be bilateral.xiv

Figure i.

The bell-clapper deformity with abnormal fixation of the tunica vaginalis to the testicle.

Differential Diagnosis

  • Abstract
  • Historic period Distribution
  • Differential Diagnosis
  • Physical Examination
  • Imaging
  • Direction
  • References

Acute scrotum is divers every bit a sudden painful swelling of the scrotum or its contents, accompanied by local signs or systemic symptoms.16 In a patient presenting with astute scrotum, information technology is imperative to rule out testicular torsion, which is a true surgical emergency.16–22 A high index of suspicion on the part of the medico is needed; children in detail may not promptly or accurately retrieve or describe symptom severity and duration.

The differential diagnosis of the astute scrotum is broad (Tabular array 123), and the proportion of patients presenting with each of these weather varies. Although nigh patients will not require emergent intervention, a pregnant minority will have testicular torsion, and prompt identification and institution of therapy are crucial.24–26 Well-nigh patients practise not present for evaluation immediately upon onset of symptoms, further limiting the therapeutic window for testicular salve.

Table 1.

Differential Diagnosis of the Acute Scrotum

Diagnosis Clinical clues

Epididymoorchitis

Altered genitourinary structure or role

Recent viral illness

Tenderness in testicle or epididymis

Hematologic disorders

Abnormal laboratory values

Diffusely difficult testicle (in leukemia or lymphoma)

History of hematologic disorders

Idiopathic scrotal edema

No signs or symptoms of infection

Swelling of overlying scrotal peel

Infection

Aberrant urinalysis

Altered genitourinary beefcake

Epididymal or testicular tenderness

Fever

Inguinal hernia or hydrocele

Fluctuation of swelling or mass throughout twenty-four hour period or with activity

Groin mass

Torsion of the appendix testicle or appendix epididymis

Blue dot sign Tenderness over the head of the testicle or epididymis

Torsion of the spermatic cord

Absent or decreased blood flow on ultrasonography

Loftier-riding testicle

Nausea, vomiting, or both

Palpable twist in cord

Sudden onset of symptoms

Trauma

Ecchymosis

History of trauma or mechanism of injury

Tumor

Elevated tumor markers or aberrant

laboratory test results

Hard mass within testicle

Systemic symptoms (if metastatic)

Varicocele

Dull, aching pain

Fluctuation of swelling or hurting throughout twenty-four hours or with activity

Physical Examination

  • Abstruse
  • Age Distribution
  • Differential Diagnosis
  • Physical Examination
  • Imaging
  • Management
  • References

The archetype presentation of testicular torsion is sudden onset of severe unilateral testicular pain associated with nausea and airsickness.sixteen–18,22,27–29 Patients may also have nonspecific symptoms such equally fever or urinary issues. Although at that place are no clear precipitating factors, many patients describe a recent history of trauma or strenuous physical activity.27 The ipsilateral scrotal peel may be indurated, erythematous, and warm, although changes in the overlying skin reverberate the degree of inflammation and may change over time.18,27 A loftier-riding testicle can indicate a twisted, foreshortened spermatic cord.xxx

The affected testicle tin likewise have an abnormal horizontal orientation. The cremasteric reflex, which is elicited past pinching the medial thigh, causes elevation of the testicle. Presence of the reflex suggests, but does not confirm, the absence of testicular torsion.18,22,31,32 Comparison of the afflicted and unaffected sides may help delineate abnormal clinical findings, although scrotal edema and patient discomfort may limit concrete test.24 Patients in whom the components of the spermatic cord can be distinctly appreciated, whose testes are normally oriented, who accept minimal to no scrotal edema, and who have no systemic symptoms (particularly with examination) are unlikely to have astute testicular torsion.18,22,27,32,33

In cases of intermittent torsion, patients typically report recurrent episodes of astute unilateral scrotal pain.16,29,30 The pain ordinarily resolves spontaneously within a few hours. Clinical exam and imaging are often normal if the patient presents after resolution of torsion. Chronic intermittent torsion may result in segmental ischemia of the testicle and warrants urologic evaluation.34

The appendix testis and appendix epididymis are embryologic remnants of the Müllerian and Wolffian systems, respectively. These vestigial structures may torse, with subsequent infarction. Clinically, torsion of an appendix tin be hard to differentiate from torsion of the spermatic string in the patient with acute scrotal pain; the onset of pain may be similarly abrupt, and systemic symptoms (although less common) may be nowadays.35 The archetype presentation of a torsed appendage is the blueish dot sign, where the inflamed and ischemic appendage can exist visualized through the scrotal skin28; overlying scrotal edema and patient complexion may limit this finding, thus decreasing the sensitivity.29,33

When patients with appendiceal torsion present early, focal tenderness at the superior pole of the epididymis, near the torsed appendage, is oftentimes appreciated. As local inflammation occurs, the development of local edema may make the diagnosis more challenging. In a serial of 119 males with acute scrotum, more than than half had torsion of a testicular appendage, whereas approximately one-third had testicular torsion.25

Patients with normal examination results, merely with pregnant tenderness along the epididymis or testicle, may take epididymoorchitis.27,28,36 Epididymitis is rare in prepubertal children, except in the presence of abnormal genitourinary anatomy or recent viral infection.37 In older patients, particularly those who are sexually active or who take recently undergone a procedure, bacteria from the float or urethra can infect the epididymis or testicle.36 History and physical test, every bit well as urinalysis, are helpful in confirming or excluding this diagnosis.36,37

Imaging

  • Abstract
  • Age Distribution
  • Differential Diagnosis
  • Physical Exam
  • Imaging
  • Direction
  • References

In patients with a history and physical test suggestive of torsion, imaging studies should not exist performed; rather, these individuals should undergo immediate surgical exploration38(Figure 2 ix). The delay associated with performing imaging tin can extend the time of testicular ischemia, thereby decreasing testicular salvage rates.17 Negative surgical exploration is preferable to a missed diagnosis because all imaging studies have a false-negative rate. Data provided by imaging studies are secondary to exam findings, and management should exist based primarily on history and physical findings.24 Patients with physical findings strongly suggestive of testicular torsion should be referred for surgical exploration regardless of ultrasound findings.16,17,33,39,40

Evaluation of the Astute Scrotum

Figure 2.

Algorithm for evaluating acute scrotal hurting.

Information from reference 9.

The well-nigh usually used imaging modality is Doppler ultrasonography,41 which is a highly sensitive (88.9%) and specific (98.8%) preoperative diagnostic tool with a 1% false-negative charge per unit.38 Doppler ultrasonography evaluates the size, shape, echogenicity, and perfusion of both testicles. Color Doppler imaging of testicular torsion demonstrates a relative decrease or absence of blood catamenia within the affected testicle.38–40,42 If blood flow is absent-minded on Doppler imaging and consequent with torsion, immediate surgical exploration is indicated.43

Radionuclide imaging too can be used to evaluate the acute scrotum.44 The technique involves injection of an isotope intravenously followed by claret flow images of the scrotum. Testicular isotope scanning can differentiate epididymitis, which results in "hot spots" acquired by increased perfusion virtually the affected testicle, from testicular torsion, which results in "cold spots" acquired by decreased claret flow to the affected testicle.45 Even so, availability, speed, and lack of radiation make ultrasonography the first-line imaging modality.38–40,42

Management

  • Abstract
  • Age Distribution
  • Differential Diagnosis
  • Physical Exam
  • Imaging
  • Management
  • References

Prompt restoration of claret menses to the ischemic testicle is critical in cases of testicular torsion,1–3 and prompt referral to a urologist is recommended.nineteen There is typically a 4- to 8-hour window earlier pregnant ischemic damage occurs, manifested by morphologic changes in testicular histopathology and deleterious effects on spermatogenesis.iii Altered semen parameters and potential decreased fertility secondary to increased permeability of the blood-testicle bulwark may not normalize even later blood menstruum has been successfully restored.46 The viability of the testicle in cases of torsion is difficult to predict; hence, emergent surgical treatment is indicated despite many patients presenting beyond the four- to viii-hour time frame.23,29 Reported testicular salvage rates are ninety% to 100% if surgical exploration is performed within six hours of symptom onset, subtract to 50% if symptoms are nowadays for more 12 hours, and are typically less than 10% if symptom duration is 24 hours or more.four,26,47 These percentages should be considered estimate rather than absolute for the purpose of counseling patients or making clinical decisions.

Manual detorsion should be attempted if surgery is not an immediate option or while preparations for surgical exploration are existence made, only should not supervene upon or delay surgical intervention.48,49 Transmission detorsion should not replace surgical exploration.4,33 The testes are typically detorsed from the medial to lateral side, turning the physician'south hands as if "opening a book."50 Analgesic administration, intravenous sedation, or a spermatic cord block may facilitate detorsion past relaxing cremasteric fibers and controlling hurting plenty to allow manipulation of the testicle for detorsion. The testicle is typically twisted more than 360 degrees, so more than one rotation may be required to completely detorse the testicle.50 The subjective end point is alleviation of pain, although analgesic assistants may limit the utility of this measure out. Render of blood menses to the testicle on Doppler ultrasonography serves as an objective end betoken and should always exist documented; yet, relative hyperemia and altered vascular flow patterns in a newly revascularized testicle may obscure ultrasound results.four

Preoperatively, patients should exist counseled on the potential need for orchiectomy every bit part of the surgical informed consent.17,33,51–53 A transscrotal surgical approach is typically used to evangelize the affected testicle into the operative field20,54,55(Effigy 3). Detorsion of the affected spermatic cord is performed until no twists are visible, and testicular viability has been assessed.

Figure three.

Torsed testicle with twisting of the spermatic string visualized.

Orchiectomy is performed if the affected testicle appears grossly necrotic or nonviable. Orchiectomy rates vary widely in the literature, typically ranging from 39% to 71% in most series.33,56,57 Historic period and prolonged time to definitive treatment have been identified as take a chance factors for orchiectomy.51,52 The charge per unit of testicular loss can approach 100% in cases where the diagnosis is missed, emphasizing the necessity of maintaining a high index of suspicion for torsion in males presenting with scrotal pain.52 If the affected testicle is deemed viable, orchiopexy with permanent suture should exist performed to permanently fix the testicle inside the scrotum.58

Contralateral orchiopexy should be performed regardless of the viability of the affected testicle.59 The bell-clapper deformity that increases testicular mobility and, therefore, the risk of torsion, is bilateral in upward to 80% of patients.xiv It is assumed to exist nowadays contralaterally in all patients with testicular torsion.26,51,53

Data Sources: Literature searches were performed in PubMed, using various combinations of the search terms testicular torsion, imaging, spermatic cord, physical exam, acute scrotum, orchiectomy, testicular function, and emergency. Search dates: November 2010, December 2010, November 2011, and July 2013.

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The Authors

prove all writer info

VICTORIA J. Precipitous, Md, MBA, is a clinical professor in the Departments of Urology and Family Medicine at the University of Iowa Carver College of Medicine in Iowa City....

KATHLEEN KIERAN, MD, is a clinical assistant professor in the Department of Urology at the University of Iowa Carver Higher of Medicine.

ANGELA M. ARLEN, MD, is a pediatric urology boyfriend at Children'due south Healthcare of Atlanta and Emory Academy in Atlanta, Ga. At the time this article was written, she was a resident in the Section of Urology at the University of Iowa Carver College of Medicine.

Address correspondence to Victoria J. Sharp, Doc, MBA, University of Iowa, 200 Hawkins Dr., iii RCP, Iowa City, IA 52242-1089 (e-post: victoria-precipitous@uiowa.edu). Reprints are not bachelor from the authors.

Writer disclosure: No relevant financial affiliations.

The authors give thanks Kris Greiner for editorial assist during preparation of the manuscript.

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