Testicular Torsion
Abstract and Commentary
By Rene J. Beckham, MD, Internal Medicine Consultant, National Imaging Associates, Phoenix, AZ, is Associate Editor for Urgent Care Alert.
Dr. Beckham reports no financial relationship to this field of study
Synopsis: Overview of diagnosis and treatment of testicular torsion.
Source: Ringdahl E, Teague L. Testicular Torsion. Am Fam Physician. 2006;74:1739-1743.
Testicular torsion occurs most frequently in males age 25 and younger and has an incidence of 1 in 4000 annually.1 There are multiple predisposing factors to testicular torsion; however, it most commonly occurs without any precipitating event.2 The mechanism of injury in testicular torsion is the rotation of the spermatic cord causes vascular obstruction which leads to testicular ischemia. The ischemia can occur anywhere from within 4 to 24 hours, depending on the degree of rotation; however, in the majority of cases it occurs within 6 hours.3 Testicular torsion is a medical condition that must be diagnosed quickly and without delay in surgical intervention, or there is risk of testicular viability.
When evaluating a patient with scrotal or testicular pain, the following differential diagnosis should be considered: trauma, epididymitis/orchitis, incarcerated hernia, varicocele, idiopathic scrotal edema, and torsion of the appendix testis (remnant of the mullerian duct at the superior pole of the testis). There are some findings on physical exam which are more specific in testicular torsion than in the aforementioned conditions. Venous congestion usually causes the affected testis to be enlarged, and the shortening of the spermatic cord may cause the testis to appear higher on the affected side. Both of these are very specific to testicular torsion. The location of the epididymis on palpation will vary depending on the degree of torsion and whether there is an absence of the cremasteric reflex.
Any patient evaluated within 6 hours of onset of pain, with a history and physical exam which are highly suspicious for torsion, should have immediate surgery. Detorsion in this time frame has been found to have a testicular salvage rate of 90%, whereas the salvage rate falls rapidly after 6 hours, and is only 10% at twenty-four hours.4 Any patient with a questionable exam, or who falls outside the 6-hour window, should have a diagnostic test. The 2 most specific tests are a Doppler ultrasonography, which evaluates blood flow in the testis and can differentiate ischemia from inflammation and other testicular disease and scintigraphy using technetium, which reveals a decrease in delivery of the radiotracer to the ischemic testis. The benefit of scintigraphy is that it has a 100% sensitivity for testicular torsion compared to an 88% sensitivity with the Doppler ultrasonography. However, the Doppler is more readily available in most medical centers, and therefore, will lead to a more rapid diagnosis.5,6
There have been cases with successful treatment of testicular torsion by manual detorsion; however, this maneuver should never delay a surgical consultation. Surgical exploration is the definitive treatment for testicular torsion and may include correction of the torsion if the testis is viable and bilateral orchiopexy to prevent future torsion or removal of the testis if it is not viable and orchiopexy to the opposite side. Loss of a testicle leads to the most significant complication in testicular torsion. There is a high risk of litigation with a missed or delayed diagnosis of testicular torsion, even when the cause for the delay is due to late presentation of the patient to a medical facility.
Commentary
Anyone working in an urgent care setting should be aware of the urgency needed in diagnosis and treatment in young males who present with testicular pain. A history of testicular trauma should not limit the suspicion and appropriate work-up to rule out testicular torsion. The age of the typical patient with torsion, and the ultimate consequence, make this a devastating problem if the diagnosis is missed or the patient is treated inappropriately.
Each patient should initially have a thorough history and physical exam and be referred quickly if there is any suspicion of testicular torsion. A call should be placed directly to a surgeon, if possible, or the emergency physician who will be accepting the patient. The patient and family must be educated on the possible diagnosis, treatment, and consequences so that they are aware of the urgency of the situation. It is not possible to control how or when patients present for care; however, once a patient with a history or exam presents to the urgent care they should be treated with urgently to prevent any further delays in treatment.
References
- Barada JH, et al. Testicular salvage and age-related delay in the presentation of testicular torsion. J Urol. 1989;142:746-748.
- Seng YJ, Moissinac K. Trauma induced testicular torsion: A reminder for the unwary. J Accid Emerg Med. 2000;17:381-382.
- Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006;74:1739-1744.
- Davenport M. ABC of general surgery in children. Acute problems of the scrotum. BMJ. 1996;312:435-437.
- Kravchick S, et al. Color Doppler sonography: Its real role in the evaluation of children with highly suspected testicular torsion. Eur Radiol. 2001;11:1000-1005.
- Wu HC, et al. Comparison of radionuclide imaging and ultrasonography in the differentiation of acute testicular torsion and inflammatory testicular disease. Clin Nucl Med. 2002;27:490-493.
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