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Pediatric Testicular Torsion Treatment & Management

  • Author: Krishna Kumar Govindarajan, MBBS, MS, DNB, MRCS, MCh; Chief Editor: Marc Cendron, MD  more...
 
Updated: Mar 30, 2015
 

Approach Considerations

Testicular torsion is a surgical emergency, and all efforts should be aimed at bringing the patient to the operating room as quickly as possible within the limits of surgical and anesthetic safety. Outcomes directly depend on the duration of ischemia; thus, time is of the essence.[2] Time wasted attempting to arrange for imaging studies, laboratory testing, or other diagnostic procedures results in lost testicular tissue.

Ongoing controversy surrounds the issue of exploration versus observation for perinatal torsion. This condition is uncommon enough that few centers see enough cases to merit any prospective studies, and medicolegal issues likely drive much of the decision-making in this area.[41, 42]

Various experimental studies in animal models have investigated ways of minimizing the testicular injury associated with ischemia and reperfusion injury. Agents as varied as superoxide dismutase, catalase, calcium channel blockers, oxypurinol, and allopurinol have been used. Other agents used include melatonin,[43] zinc aspartate,[44] and dehydroepiandrosterone.[45] Unfortunately, none of these models has yet generated adequate evidence to justify trials in humans.

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Manual Detorsion

In some cases of testicular torsion, manually untwisting the spermatic cord may allow reestablishment of vascular flow. The technique involves manipulating the involved testis so that the anterior surface rotates from medial to lateral. This is termed the open book method because the motion resembles opening the cover of a book (for a right testis).

When successful, this maneuver almost immediately relieves pain in most patients. Manual detorsion is best performed with the intention of buying time until the surgical team is ready, rather than with the intention of altogether avoiding a surgical procedure.[46]

Reports of this procedure have suggested that it is highly effective, in that it allows the acute emergency to be converted into an elective surgical procedure, with a quoted salvage rate of 100%.[8] Cornel et al report that no testicular atrophy was detected after performing a manual detorsion.[47]

In actuality, manual detorsion is difficult and rarely used. Application of this maneuver in an emergency department setting in a child with a swollen painful scrotum can be difficult or impossible without anesthesia. Furthermore, the testis may not be fully detorsed or may retorse shortly after the patient leaves the hospital. In addition, knowing which way the testis is torsed a priori is impossible; thus, attempting detorsion may simply worsen the degree of torsion.

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Surgical Exploration

The goals of surgical exploration are as follows:

  • Confirmation of the diagnosis of torsion
  • Detorsion of the involved testis
  • Assessment of the viability of the involved testis
  • Removal of the involved testis (if it is nonviable) or fixation (if it is viable)
  • Fixation of the contralateral testis, when appropriate

Because of the concern regarding the possibility of asynchronous testicular torsion, contralateral exploration and fixation is widely performed.[48, 49]

The argument against surgical exploration includes the low probability of salvage in the setting of old torsion (>24-48 hours). However, proponents of surgery argue that in view of the medicolegal implications, exploration must be performed to prove the diagnosis, to salvage the testis (if possible), and to concurrently perform a contralateral orchidopexy. Indeed, surgeons rarely experience medicolegal consequences for a negative exploration finding in the setting of acute scrotum, whereas lawsuits for failure to explore are routine.[50]

Indications for surgery

In the neonate with acute scrotum at birth or a few days afterward, surgical recommendations are controversial. Although most authorities recommend exploration of the ipsilateral side and fixation of the contralateral testis, some have suggested that observation is acceptable because of the negligible salvage rate of the ischemic testis and the low incidence of contralateral torsion. The risk of anesthesia in children younger than 1 year may also factor into decision-making process.

In the prepubertal boy with acute scrotum, exploration with salvage of the ipsilateral testis is recommended, if possible. If testicular torsion is confirmed, contralateral orchiopexy is recommended. Differential diagnoses to consider include torsed appendix epididymis ("blue-dot sign") and epididymitis. If a clear-cut blue-dot sign is identified and confirmed with Doppler ultrasonography, a conservative approach is justified.

In the adolescent with acute scrotum, exploration with salvage of the ipsilateral testis is recommended, if possible. If torsion is confirmed, contralateral orchiopexy is recommended. If the testis has not been salvaged, ipsilateral orchiectomy is usually performed.

Intraoperative details

Exploration can involve a paramedian scrotal incision, a transverse incision, or a single midline scrotal incision. Some surgeons prefer to explore the acute scrotum through an inguinal incision, theorizing that this approach offers better control of the high spermatic cord if the exploration reveals an unexpected diagnosis (eg, testis tumor).

It may be difficult to intraoperatively determine whether a testis of marginal viability should be retained or excised. Although retaining a marginal testis may appear to carry no negative consequences, long-term concerns about the immunologic consequences of the infarcted testis have been raised. Testicular ischemia disrupts the blood-testis barrier, which may result in autoimmunization against spermatozoa and formation of antisperm antibodies; this may affect sperm produced by both testes.

However, both spermatogenesis and the blood-testis barrier are established after age 10 years; thus, some surgeons always retain the doubtful testis in children younger than 10 years.[6]

Arda et al recommend that the testis be incised at exploration to look for bleeding as a measure of viability. Bleeding is graded as follows[51] :

  • Grade I - Immediate bleeding
  • Grade II - Bleeding after 10 minutes
  • Grade III - No bleeding after 10 minutes

Excision of the testis is recommended for grade III.

Once the testis has been detorsed and the decision is made to preserve it, the tunica vaginalis is everted, as in a Jaboulay procedure; two or three sutures are passed through the dartos and tunica albuginea of the testicle. Some surgeons avoid placing sutures directly into the tunica albuginea, out of concern for disrupting the blood-testis barrier; instead, they place the sutures into the visceral tunica vaginalis of the mesorchium.[52]

Kuntze et al reported that absorbable sutures predispose to recurrent torsion after orchiopexy; thus, nonabsorbable sutures are recommended for securing the testis.[53]

Window orchidopexy has been performed to ensure better fixation of the testis and thus avoid recurrent torsion, based on the principle that creating a window in the tunica vaginalis makes a broad area of dense adhesion during healing, resulting in better apposition.[54] Sutureless fixation in a dartos pouch has been reported for neonatal orchiopexy when performing a contralateral exploration.

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Long-Term Monitoring

Although long-term observation to monitor for testicular atrophy would be helpful in patients with testicular torsion, in actuality, many of these patients (particularly the adolescents) do not return for follow-up. In patients who do return, annual scrotal ultrasonography during the 2-3 years after surgery can be used to document testicular volume and growth.

Recurrent torsion following an orchiopexy is possible (though rare) and may occur several years after the initial fixation of the testis. Thus, patients and parents should be forewarned about this risk and should promptly seek medical care if testicular pain occurs, even after an orchiopexy has been performed.[31]

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Contributor Information and Disclosures
Author

Krishna Kumar Govindarajan, MBBS, MS, DNB, MRCS, MCh MNAMS, FAIS, FICS, FACS, FEBPS, Assistant Professor and Consultant Pediatric Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research, India

Krishna Kumar Govindarajan, MBBS, MS, DNB, MRCS, MCh is a member of the following medical societies: American College of Surgeons, International College of Surgeons, British Association of Paediatric Surgeons, Association of Surgeons of India, Indian Association of Pediatric Surgeons, Association of Colon and Rectal Surgeons of India, Association of Minimal Access Surgeons of India, National Academy of Medical Sciences (India)

Disclosure: Nothing to disclose.

Coauthor(s)

Caleb P Nelson, MD, MPH Assistant Professor of Surgery (Urology), Department of Urology, Harvard Medical School; Consulting Staff, Department of Urology, Children's Hospital Boston

Caleb P Nelson, MD, MPH is a member of the following medical societies: American Urological Association, Endourological Society, Phi Beta Kappa, Society for Pediatric Urology, Society for Fetal Urology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Marc Cendron, MD Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston

Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, New Hampshire Medical Society, Society for Pediatric Urology, Society for Fetal Urology, Johns Hopkins Medical and Surgical Association, European Society for Paediatric Urology

Disclosure: Nothing to disclose.

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Perinatal testicular torsion.
Intravaginal testicular torsion with ischemia in adolescent boy.
Torsion of undescended testis.
Torsion of testis, with cord twist clearly demonstrated.
Torsion of appendix testis.
 
 
 
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