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Pediatric Testicular Torsion Workup

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

Approach Considerations

Although contemporary imaging techniques will correctly reveal testicular torsion in most cases, pediatric urologists and surgeons have been hesitant to rely too heavily on these diagnostic tests. Concerns over false-negative findings and the lengthy wait necessary to complete studies at some centers (and the lack of availability of radiology services of any kind at certain hours) have led many surgeons to rely on the clinical history and examination to guide the decision for surgery in most cases.

According to this philosophy, a negative finding on surgical exploration is indeed a better outcome than a necrotic testis due to a missed diagnosis. Such practices are reinforced by medicolegal concerns, particularly given the well-documented incidence of false-negative imaging results.[32, 33] Thus, at many centers, imaging studies are used primarily when the diagnosis is uncertain but the index of suspicion for testicular torsion is low.


Doppler Ultrasonography

The most widely used imaging modality for evaluation of testicular torsion is ultrasonography with Doppler scanning for blood flow. An absent Doppler signal in the testicular parenchyma is diagnostic of testicular torsion. Initial parenchymal echogenicity is decreased but may increase once infarction has ensued.

As with any ultrasonographic modality, however, Doppler scanning is highly operator-dependent. Important factors to consider include the presence or absence of blood flow in the central parts of the testis, taking into account the Doppler signals only from the centripetal branches of the testicular artery, minimizing motion artifact, and carefully comparing findings with the contralateral testis to make a confident decision.[32]

A markedly enlarged, echogenic, and avascular/hypovascular epididymis is an ancillary ultrasonographic sign in testicular torsion. A hypervascular enlarged epididymis can occur in 5% of cases and should not be dismissed as epididymitis.[34] In old torsion, the testis size is small, appearing echo-poor, with a prominent, enlarged epididymis. In cases of intermittent and early testicular torsion, false-negative findings can be expected.

Ultrasonography can be used to differentiate extratesticular pathology (eg, hydrocele, abscess, wall edema, and hematoma) from testicular etiologies (eg, tumor and torsion). Ultrasonography is often helpful in diagnosing epididymo-orchitis, characterized by increased blood flow to the testis and epididymis. In case of a torsed testicular appendage, an extra testicular hyperechogenic nodule can be identified between the head of the epididymis and the upper pole of the testis.[29]

Overall, ultrasonography with Doppler has been reported to yield a sensitivity of 88% and specificity of 90% for identifying testicular torsion. However, the sensitivity and specificity of this modality widely varies among institutions, depending on factors ranging from equipment to operator and radiologist experience. False-positive findings can be particularly troublesome in infants because of difficult flow detection in prepubescent testes.[35, 36]


High-Resolution Ultrasonography

Ultrasonography with a high-resolution probe (at least a 7.5-MHz transducer) is a recent addition to the armamentarium to detect testicular torsion. This study is used to examine the cord in its entirety, from the inguinal canal downward, to detect a spiral twist, yielding a sensitivity of 97.3% and a specificity of 99% in confirming torsion.

High-resolution ultrasonography has been reported to be superior to Doppler ultrasonography alone. Again, the concern is that the findings are operator-dependent. This study is widely used in tertiary care centers but may not be available in many community or rural settings.[37]


Nuclear Scanning

Radioisotope scanning has been reported to be highly accurate for diagnosis of testicular torsion. The ischemic area is seen as a photopenic zone in testicular ischemia. In cases of inflammation and infection, increased uptake is seen.

Unfortunately, this modality is not widely available, and even centers with functioning nuclear medicine capabilities may not have these available at all hours. For this reason, ultrasonography imaging is more widely used in the United States in most settings. Radioisotope scanning involves a low dose of radiation (2 mSv).[38]


Other Studies

Urinalysis may help to suggest an infectious etiology of scrotal pain when positive for pyuria and bacteriuria; however, urinalysis should not be allowed to delay treatment in cases where acute testicular torsion is suspected.

Some authors are exploring the use of near-infrared spectroscopy (NIRS) to study and compare the tissue saturation index on the right and left spermatic cords and thereby identify testicular torsion.[39, 40]

Contributor Information and Disclosures

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.


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.

  1. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006 Nov 15. 74(10):1739-43. [Medline].

  2. Chapman RH, Walton AJ. Torsion of the testis and its appendages. Br Med J. 1972 Jan 15. 1(5793):164-6. [Medline]. [Full Text].

  3. Gilchrist BF, Lobe TE. The acute groin in pediatrics. Clin Pediatr (Phila). 1992 Aug. 31(8):488-96. [Medline].

  4. Mac Nicol. Torsion of testis in childhood. Br Med J. 1974. 61:905-8.

  5. Nadel NS, Gitter MH, Hahn LC, Vernon AR. Preoperative diagnosis of testicular torsion. Urology. 1973 May. 1(5):478-9. [Medline].

  6. Hutson J. Undescended testis, torsion, and varicocoele. Grosfeld JL, et al. Pediatric Surgery. 2006. 1193-214.

  7. Gatti JM, Patrick Murphy J. Current management of the acute scrotum. Semin Pediatr Surg. 2007 Feb. 16(1):58-63. [Medline].

  8. Cattolica EV. Preoperative manual detorsion of the torsed spermatic cord. J Urol. 1985 May. 133(5):803-5. [Medline].

  9. Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA. Testicular torsion: direction, degree, duration and disinformation. J Urol. 2003 Feb. 169(2):663-5. [Medline].

  10. Mansbach JM, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005 Dec. 159(12):1167-71. [Medline].

  11. Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. 1994 Jul. 44(1):114-6. [Medline].

  12. Cilento BG, Najjar SS, Atala A. Cryptorchidism and testicular torsion. Pediatr Clin North Am. 1993 Dec. 40(6):1133-49. [Medline].

  13. Ferro F, Iacobelli B. Polyorchidism and torsion. A lesson from 2 cases. J Pediatr Surg. 2005 Oct. 40(10):1662-4. [Medline].

  14. Favorito LA, Cavalcante AG, Costa WS. Anatomic aspects of epididymis and tunica vaginalis in patients with testicular torsion. Int Braz J Urol. 2004 Sep-Oct. 30(5):420-4. [Medline].

  15. Anderson JB, Williamson RC. Testicular torsion in Bristol: a 25-year review. Br J Surg. 1988 Oct. 75(10):988-92. [Medline].

  16. King P, Sripathi V. The acute scrotum. Ashcraft KW et al. Pediatric Surgery. 2005. 717-22.

  17. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. 1976 Jun. 63(6):465-76. [Medline].

  18. Ramachandra P, Palazzi KL, Holmes NM, Marietti S. Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center. West J Emerg Med. 2015 Jan. 16(1):190-4. [Medline]. [Full Text].

  19. Davenport M. ABC of general surgery in children. Acute problems of the scrotum. BMJ. 1996 Feb 17. 312(7028):435-7. [Medline]. [Full Text].

  20. Bennett S, Nicholson MS, Little TM. Torsion of the testis: why is the prognosis so poor?. Br Med J (Clin Res Ed). 1987 Mar 28. 294(6575):824. [Medline]. [Full Text].

  21. Nasrallah P, Nair G, Congeni J, Bennett CL, McMahon D. Testicular health awareness in pubertal males. J Urol. 2000 Sep. 164(3 Pt 2):1115-7. [Medline].

  22. Tryfonas G, Violaki A, Tsikopoulos G, Avtzoglou P, Zioutis J, Limas C, et al. Late postoperative results in males treated for testicular torsion during childhood. J Pediatr Surg. 1994 Apr. 29(4):553-6. [Medline].

  23. Scheiber K, Marberger H, Bartsch G. Exocrine and endocrine testicular function in patients with unilateral testicular disease. J R Soc Med. 1983 Aug. 76(8):649-51. [Medline]. [Full Text].

  24. Ozkan KU, Küçükaydin M, Muhtaroglu S, Kontas O. Evaluation of contralateral testicular damage after unilateral testicular torsion by serum inhibin B levels. J Pediatr Surg. 2001 Jul. 36(7):1050-3. [Medline].

  25. Puri P, Barton D, O'Donnell B. Prepubertal testicular torsion: subsequent fertility. J Pediatr Surg. 1985 Dec. 20(6):598-601. [Medline].

  26. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol. 1984 Jul. 132(1):89-90. [Medline].

  27. Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg. 2003 Aug. 38(8):1248-9. [Medline].

  28. Kalfa N, Veyrac C, Lopez M, Lopez C, Maurel A, Kaselas C, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007 Jan. 177(1):297-301; discussion 301. [Medline].

  29. Karmazyn B, Steinberg R, Livne P, Kornreich L, Grozovski S, Schwarz M, et al. Duplex sonographic findings in children with torsion of the testicular appendages: overlap with epididymitis and epididymoorchitis. J Pediatr Surg. 2006 Mar. 41(3):500-4. [Medline].

  30. Lewis RL, Roller MD, Parra BL, Cotlar AM. Torsion of an intra-abdominal testis. Curr Surg. 2000 Sep 1. 57(5):497-499. [Medline].

  31. Mor Y, Pinthus JH, Nadu A, Raviv G, Golomb J, Winkler H, et al. Testicular fixation following torsion of the spermatic cord--does it guarantee prevention of recurrent torsion events?. J Urol. 2006 Jan. 175(1):171-3; discussion 173-4. [Medline].

  32. Steinhardt GF, Boyarsky S, Mackey R. Testicular torsion: pitfalls of color Doppler sonography. J Urol. 1993 Aug. 150(2 Pt 1):461-2. [Medline].

  33. Ingram S, Hollman AS, Azmy A. Testicular torsion: missed diagnosis on colour Doppler sonography. Pediatr Radiol. 1993. 23(6):483-4. [Medline].

  34. Nussbaum Blask AR, Rushton HG. Sonographic appearance of the epididymis in pediatric testicular torsion. AJR Am J Roentgenol. 2006 Dec. 187(6):1627-35. [Medline].

  35. Schalamon J, Ainoedhofer H, Schleef J, Singer G, Haxhija EQ, Höllwarth ME. Management of acute scrotum in children--the impact of Doppler ultrasound. J Pediatr Surg. 2006 Aug. 41(8):1377-80. [Medline].

  36. Kravchick S, Cytron S, Leibovici O, Linov L, London D, Altshuler A, et al. Color Doppler sonography: its real role in the evaluation of children with highly suspected testicular torsion. Eur Radiol. 2001. 11(6):1000-5. [Medline].

  37. Sidhu PS. Clinical and imaging features of testicular torsion: role of ultrasound. Clin Radiol. 1999 Jun. 54(6):343-52. [Medline].

  38. Luscombe CJ, Mountford PJ, Coppinger SM, Gadd R. Diagnosing testicular torsion. Isotope scanning is useful. BMJ. 1996 May 25. 312(7042):1358-9. [Medline]. [Full Text].

  39. Shadgan B, Fareghi M, Stothers L, Macnab A, Kajbafzadeh AM. Diagnosis of testicular torsion using near infrared spectroscopy: A novel diagnostic approach. Can Urol Assoc J. 2014 Mar. 8(3-4):E249-52. [Medline]. [Full Text].

  40. Schoenfeld EM, Capraro GA, Blank FS, Coute RA, Visintainer PF. Near-infrared spectroscopy assessment of tissue saturation of oxygen in torsed and healthy testes. Acad Emerg Med. 2013 Oct. 20(10):1080-3. [Medline].

  41. Cuervo JL, Grillo A, Vecchiarelli C, Osio C, Prudent L. Perinatal testicular torsion: a unique strategy. J Pediatr Surg. 2007 Apr. 42(4):699-703. [Medline].

  42. Lee SD, Cha CS. Asynchronous bilateral torsion of the spermatic cord in the newborn: a case report. J Korean Med Sci. 2002 Oct. 17(5):712-4. [Medline]. [Full Text].

  43. Abasiyanik A, Dagdönderen L. Beneficial effects of melatonin compared with allopurinol in experimental testicular torsion. J Pediatr Surg. 2004 Aug. 39(8):1238-41. [Medline].

  44. Ozkan KU, Boran C, Kilinç M, Garipardiç M, Kurutas EB. The effect of zinc aspartate pretreatment on ischemia-reperfusion injury and early changes of blood and tissue antioxidant enzyme activities after unilateral testicular torsion-detorsion. J Pediatr Surg. 2004 Jan. 39(1):91-5. [Medline].

  45. Aksoy H, Yapanoglu T, Aksoy Y, Ozbey I, Turhan H, Gursan N. Dehydroepiandrosterone treatment attenuates reperfusion injury after testicular torsion and detorsion in rats. J Pediatr Surg. 2007 Oct. 42(10):1740-4. [Medline].

  46. Garel L, Dubois J, Azzie G, Filiatrault D, Grignon A, Yazbeck S. Preoperative manual detorsion of the spermatic cord with Doppler ultrasound monitoring in patients with intravaginal acute testicular torsion. Pediatr Radiol. 2000 Jan. 30(1):41-4. [Medline].

  47. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int. 1999 Apr. 83(6):672-4. [Medline].

  48. Frank JD, O'Brien M. Fixation of the testis. BJU Int. 2002 Mar. 89(4):331-3. [Medline].

  49. Olguner M, Akgür FM, Aktug T, Derebek E. Bilateral asynchronous perinatal testicular torsion: a case report. J Pediatr Surg. 2000 Sep. 35(9):1348-9. [Medline].

  50. Kass EJ, Stone KT, Cacciarelli AA, Mitchell B. Do all children with an acute scrotum require exploration?. J Urol. 1993 Aug. 150(2 Pt 2):667-9. [Medline].

  51. Arda IS, Ozyaylali I. Testicular tissue bleeding as an indicator of gonadal salvageability in testicular torsion surgery. BJU Int. 2001 Jan. 87(1):89-92. [Medline].

  52. Steinbecker KM, Teague JL, Wiltfong DB, Wakefield MR. Testicular histology after transparenchymal fixation using polytetrefluoroethylene suture: an animal model. J Pediatr Surg. 1999 Dec. 34(12):1822-5. [Medline].

  53. Kuntze JR, Lowe P, Ahlering TE. Testicular torsion after orchiopexy. J Urol. 1985 Dec. 134(6):1209-10. [Medline].

  54. Morse TS, Hollabaugh RS. The "window" orchidopexy for prevention of testicular torsion. J Pediatr Surg. 1977 Apr. 12(2):237-40. [Medline].

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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