Definition
Key History
Key Physical Exam
Risk Factors for Testicular Torsion
Differential Diagnosis
Torsion vs. Epididymitis Table
Testicular Salvage Rates Table
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
In testicular torsion the spermatic cord that provides the blood supply to a testicle
is twisted, cutting off the blood supply, often causing orchalgia. Prolonged testicular
torsion will result in the death of the testicle and surrounding tissues.
It is also believed that torsion occurring during fetal development can lead to
the so-called neonatal torsion or vanishing testis, and is one of the causes of
an infant being born with monorchism.
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- History of similar pain that resolved spontaneously (up to 41%)
- Sudden onset pain in inguinal or lower abdomen
- Key: Sometimes only lower abdominal pain without inguinal or scrotal
pain
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- Often associated with nausea and vomiting
- Commonly occurs after sleep, exertion, or direct trauma
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- Hemiscrotum extremely painful to touch – limiting exam
- Hemiscrotum swollen, tender and firm
- Reactive hydrocele may be present.
- May have high riding testis with a transverse lie – classic finding
- Loss of cremasteric reflex has strong association with torsion.
- Blue dot sign – Blue/black dot in scrotum associated with testicular
appendage torsion
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- Prehn’s sign – elevation of scrotum relieves pain from epididymitis but
not torsion
(not reliable)
- Opposite testis should be examined for bell-clapper deformity.
- Tenderness of the testicle and epididymis
- Testicular lie: Vertical is normal, horizontal is abnormal
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Age
Torsion occurs more commonly in children and adolescents, while epididymitis is
more common in older adolescents and young adults; however, there is a significant
age overlap in these groups. The testicles’ scrotal attachments are poorly developed
in neonates, making them somewhat more prone to torsion.
The most common age at which testicular torsion occurs is during puberty, and the
second most common is in the newborn. Although testicular torsion can occur at any
age, the presentation of a patient under the age of 17 with scrotal pain should
evoke a rapid response from the office or emergency department staff and should
be considered a testicular torsion until proven otherwise.
The Bell-Clapper Deformity
The normal testicle is surrounded by tunica vaginalis, including an attachment to
the posterior scrotal wall. In those persons with the bell-clapper deformity, the
tunica completely surrounds the testicle and extends above it, preventing the attachment
to the posterior scrotal wall. The testicle is freely movable on the spermatic cord,
and it can twist on the spermatic cord.
Prior Torsion
Patients with torsion should have surgical fixation of the non-torsed testicle in
order to avoid a recurrent torsion. Presumably, the same anatomic abnormality that
resulted in the initial torsion will affect the other testicle. If the patient with
a history of torsion has not had surgical fixation of the other testicle, he is
at high risk for recurrent torsion.
Undescended Testicle:
The undescended testes undergo torsion 10 times as frequently as normally descended
testes.
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- Epididymitis
- Orchitis
- Torsion of the appendix testis
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- Fournier’s gangrene
- Urinary tract infection
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Epididymitis is the most frequent misdiagnosis in cases of testicular torsion. The
delay caused by the misdiagnosis can result in testicular loss. It is important
to be able to differentiate the two or, if unable to do so, order an imaging study.
The clinician must be able to reasonably conclude that the problem is epididymitis
or consider an imaging study to rule out torsion.
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Torsion vs. Epididymitis
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Torsion |
Epididymitis |
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Onset of pain: acute |
Onset of pain: gradual |
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Vomiting and anorexia are common |
Vomiting and anorexia are uncommon |
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History of prior episodes |
No history of prior episodes |
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Fever and dysuria unusual |
Fever in 14% to 28% of cases |
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Cremasteric reflex absent |
Cremasteric reflex present |
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Testicular lie: horizontal |
Testicular lie: vertical |
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Negative Prehn's sign |
Positive Prehn's sign |
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No urethral discharge |
Urethral discharge possible |
It may be possible to differentiate tenderness in the epididymis versus the testicle
early in either process. Later in the process, however, diffuse tenderness to palpation
of both the epididymis and testicle can occur with both clinical entities. In addition,
although pyuria is typical of epididymitis, it can occur in torsion, as inflammation
becomes widespread.
One group of researchers found that patients with 3 findings from the following
list had definite epididymitis, and those with 2 findings were probable cases of
epididymitis:
- Gradual onset of symptoms
- Recent urinary tract instrumentation or surgery
- Dysuria or recent urinary tract infection
- Significant elevation in temperature – over 101 F (38.3 F)
- Localized tenderness and induration of epididymis
- Abnormal urinalysis
It is common for some doubt to remain, in which case the practitioner may consider
ordering an imaging study.
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Torsion Salvage Rates |
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Approximate % of Salvage Rate |
If Correction Occurs Within |
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100% |
3 hours |
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83% to 90% |
5 hours |
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75% |
8 hours |
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50% to 70% |
10 hours |
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10% to 20% |
10 to 24 hours |
Viability is rare if intervention is delayed for 24 hours or longer from the onset
of symptoms.
In series of 238 patients with acute scrotal pain, there was a high probability
of testicular salvage if intervention occurred within 6 hours of the onset of pain,
50% between 6 and 48 hours, and no salvage was achieved after 48 hours. One conclusion
from this study was that a testis should not be presumed necrotic and unsalvageable
if fewer than 48 hours have elapsed since the onset of symptoms.
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Text / literature information and recommendations include:
- Labs:
- Urinalysis – may be unremarkable, up to 10% have pyuria
- CBC – often absence of leukocytosis
- Imaging:
- Color Doppler Ultrasound – Test of Choice – Sensitivity 86-100% and
Specificity
100%
- Radioisotope Scans – less practical – may delay diagnosis - Sensitivity 80-100%
and Specificity 89-100%
- Doppler Ultrasound - Sensitivity 80-90%, Specificity 80-90%
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- In a man under 40 with a painful testicle, assume torsion until proven otherwise.
- If high suspicion for torsion, contact a urologist immediately, do not wait on
Doppler
findings in patients strongly suspicious of torsion. This is a seconds-to-minutes
emergency.
- Be aware that patient’s may undergo spontaneous detorsion and complete resolution
of symptoms. If discharged, provide discharge instructions to return immediately
for change in condition.
- Nearly 41% of patients report a history of a similar pain that resolved
spontaneously.
- Torsion commonly occurs after sleep, exertion, or trauma.
- Torsion may be misdiagnosed as epididymitis.
- Differentiation of Torsion vs. Epididymitis Table
- Diagnosis of testicular torsion must be made rapidly, since salvage of the testicle
becomes increasingly difficult with surgical delay. Based on several series, the
following salvage rates have been reported:
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Common text / literature recommendations include:
- Consultation with Urologist
- IV access
- Pain control
- NPO
- Manual detorsion – testis usually twist medially – only a temporary solution –
surgical
follow-up required
- To manually detorse, rotate the anterior aspect of the testicle towards the
ipsilateral
thigh - like opening a book - the testicle may need to be rotated up to 360
degrees.
If successful the patient should experience marked relief of pain.
- Surgery is curative.
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