AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle. In adolescent males, testicular torsion is the most frequent cause of testicle loss.

Pathophysiology

The testicle is typically covered by the tunica vaginalis, a potential space that encompasses the anterior two thirds of the testicle and where fluid from a variety of sources may accumulate. The tunica vaginalis attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum.

In patients who have an inappropriately high attachment of the tunica vaginalis, the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly, called the bell clapper deformity, results in the long axis of the testicle to become oriented transversely rather than cephalocaudal. This congenital abnormality is present in approximately 12% of males, 40% of which have the abnormality in the contralateral testicle as well. The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord, causing venous occlusion and engorgement, with subsequent arterial ischemia causing infarction of the testicle. Experimental evidence indicates that 720° torsion is required to compromise flow through the testicular artery and result in ischemia.

In the neonatal age group, the testicle frequently has not yet descended into the scrotum, where it becomes attached within the tunica vaginalis. This mobility of the testicle predisposes it to torsion (extravaginal testicular torsion). Inadequate fusion of the testicle to the scrotal wall, moreover, typically occurs within the first 7-10 days of life.

Frequency

United States

Incidence of torsion in males younger than 25 years is approximately 1 in 4000. Torsion more often involves the left testicle.

Of the cases of testicular torsion that occur in the neonatal population, 70% occur prenatally and 30% occur postnatally.

Mortality/Morbidity

This urologic emergency requires prompt diagnosis, immediate urologic referral, and rapid definitive treatment for salvage of the testicle.

A salvage rate of 100% is found in patients who undergo detorsion within 6 hours of pain; 20% viability rate if detorsion occurs after 12 hours; and 0% viability if detorsion is delayed greater than 24 hours.

Sex

Testicular torsion affects males only.

Age

Testicular torsion most often is observed in males younger than 30 years, with most aged 12-18 years. The peak age is 14 years, although a smaller peak also occurs during the first year of life.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• History includes a sudden onset of severe unilateral scrotal pain.
• As many as 50% of patients have a history of prior episodes of intermittent testicular pain that has resolved spontaneously (intermittent torsion and detorsion).
• Onset of pain can occur more slowly, but this is an uncommon presentation of torsion.
• Torsion can occur with activity, be related to trauma, or develop during sleep and includes the following:
• • Scrotal swelling
  • Nausea and vomiting (20-30%)
  • Abdominal pain (20-30%)
  • Fever (16%)
  • Urinary frequency (4%)

Physical

• Involved testicle painful to palpation; frequently elevated in position when compared with the other side
• Horizontal lie of the testicle
• Enlargement and edema of the testicle; edema involving the entire scrotum
• Scrotal erythema
• Ipsilateral loss of the cremasteric reflex
• Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign])
• Fever (uncommon)

Causes

• Congenital anomaly; bell clapper deformity
• Undescended testicle
• Sexual arousal and/or activity
• Trauma
• Exercise
• Active cremasteric reflex
• Cold weather

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Traumatic rupture
Traumatic hematoma
Torsion of testicular appendage

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Urinalysis
• • Urinalysis result is usually normal.
  • The presence of white blood cells (WBCs) can be observed in as many as 30% of patients who have torsion; therefore, do not rely on WBC presence to exclude the diagnosis.
• Complete blood count: CBC can be normal or show an elevated WBC count in as many as 60% of patients who have torsion.
• Acute-phase proteins (C-reactive protein [CRP]): Elevation in acute-phase proteins, namely the CRP, has been postulated as a diagnostic aid in differentiating inflammatory causes of acute scrotal pain (epididymitis) from noninflammatory causes (testicular torsion). However, sample sizes in these studies have been too small to definitively rule out testicular torsion using CRP as a diagnostic adjunct.

Imaging Studies

• Testicular torsion is a clinical diagnosis. Imaging studies usually are not necessary; ordering them wastes valuable time when the definitive treatment is surgical.
• If the diagnosis is equivocal, radionuclide scan of the testicles can be helpful to assess blood flow and to differentiate torsion from other conditions.
• • Scan is abnormal in torsion when it demonstrates decreased uptake in the affected testicle, suggesting no blood flow to that side.
  • Radionuclide scans have a sensitivity of 90-100% accuracy in detecting testicular blood flow.
• Color Doppler ultrasonography increasingly is being used to demonstrate arterial blood flow to the testicle while providing information about scrotal anatomy and other testicular disorders. Color Doppler has a sensitivity of 86%, specificity of 100%, and accuracy of 97% in the diagnosis of testicular torsion when the presence of identifiable intratesticular flow is the sole criterion for diagnosis.
• • Plain Doppler ultrasonography is less accurate than color Doppler in assessing testicular blood flow.
  • The hospital's radiology department usually provides ultrasound services. Some smaller studies have evaluated emergency medicine physicians performing bedside ultrasonography to evaluate for testicular torsion. While these studies have had generally favorable outcomes, diagnostic accuracy is always operator and institution dependent.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

• Early diagnosis and prompt urologic referral is essential since time is critical in salvage of the testicle.
• Mild analgesic pain relief can be administered once testicular torsion has been diagnosed or while awaiting further studies.
• Some consultants prefer no analgesics be administered so that their examination is not biased.
• Attempt manual detorsion, which can be attempted with pain relief as the guide for successful detorsion. The procedure is similar to the "opening of a book" when the physician is standing at the patient's feet.
• Most torsions twist inward and toward the mid line; thus, manual detorsion of the testicle involves twisting outward and laterally.
• • For example, in a suspected torsion of the right testicle, the physician is in front of the standing or supine patient and holds the patient's right testicle with the left thumb and forefinger.
  • The physician then rotates the right testicle outward 180° in a medial to lateral direction.
  • Rotation of the testicle may need to be repeated 2-3 times for complete detorsion and to provide pain relief to the patient.
  • For the patient's left testicle, the physician uses the right thumb and forefinger and rotates the patient's left testicle in an outward direction 180° from medial to lateral.
  • Manual detorsion is successful in 30-70% of patients.

Consultations

If the clinical diagnosis of torsion is suspected, early urologic consultation is mandatory since definitive treatment is surgery for detorsion and orchiopexy.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Administer pain relief judiciously and cautiously after the diagnosis of torsion is made. Some urologists prefer no analgesics be administered so their evaluation and examination of the patient are not prejudiced.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have sustained painful trauma.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Transfer

• Transfer the patient if no urologist is available.

Complications

• Infarction of testicle
• Loss of testicle
• Infection
• Infertility secondary to loss of testicle
• Cosmetic deformity

Prognosis

• If diagnosed early, a near 100% salvage rate for the testicle is possible. Orchiopexy is not a guarantee against future torsion, though it does reduce the odds of a future torsion.

Patient Education

• For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education article Testicular Pain.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to recognize a urologic emergency
• Delay in obtaining urologic consultation
• Misdiagnosing as epididymitis
• Partial reduction of a torsion (ie, 720°)

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. Mar 2000;105(3 Pt 1):604-7. [Medline].
• Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med. Jan 2001;8(1):90-3. [Medline].
• Blank BH, Goldsmith G, Schneider RE. Recognizing a testicular emergency. Patient Care. 1997;31(13):117-35.
• Brenner JS, Ojo A. Evaluation of scrotal pain or swelling in children and adolescents. UpToDate [web site]. 2006.
• Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate [web site]. 2006.
• Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. Jul 1994;44(1):114-6. [Medline].
• Cattolica EV, Karol JB, Rankin KN, Klein RS. High testicular salvage rate in torsion of the spermatic cord. J Urol. Jul 1982;128(1):66-8. [Medline].
• Cattolica EV. Preoperative manual detorsion of the torsed spermatic cord. J Urol. May 1985;133(5):803-5. [Medline].
• Doehn C, Fornara P, Kausch I, et al. Value of acute-phase proteins in the differential diagnosis of acute scrotum. Eur Urol. Feb 2001;39(2):215-21. [Medline].
• Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63. [Medline].
• Eyre RC. Evaluation of the acute scrotum in adults. UpToDate [web site].
• Flanigan RC, DeKernion JB, Persky L. Acute scrotal pain and swelling in children: a surgical emergency. Urology. Jan 1981;17(1):51-3. [Medline].
• Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. Jul 1998;102(1 Pt 1):73-6. [Medline].
• McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am. Nov 2003;21(4):909-35. [Medline].
• Schwab R. Acute scrotal pain requires quick thinking and plan of action. Emerg Med Rep. 1992;13(2):11-7.
• Wan J, Bloom DA. Genitourinary problems in adolescent males. Adolesc Med. Oct 2003;14(3):717-31, viii. [Medline].
• Weber DM, Rosslein R, Fliegel C. Color Doppler sonography in the diagnosis of acute scrotum in boys. Eur J Pediatr Surg. Aug 2000;10(4):235-41. [Medline].

Article Last Updated: Dec 13, 2006