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Testicular Torsion Workup

  • Author: Oreoluwa I Ogunyemi, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 11, 2015
 

Approach Considerations

If testicular torsion is clinically suggested, perform immediate surgical exploration, regardless of laboratory studies because a negative finding upon exploration of the scrotum is more acceptable than the loss of a salvageable testis.

Laboratory tests are unlikely to be of consequence, as no single test has high sensitivity or specificity in diagnosing testicular torsion. However, when there is a strong suspicion of an alternate diagnosis, laboratory tests may be of some use.

Imaging studies usually are not necessary. Ordering them wastes valuable time when the definitive treatment is emergent urologic consultation for surgical management. However, imaging studies (eg, ultrasonography, nuclear scans) may be useful when a low suspicion of testicular torsion exists.

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Urinalysis

If the patient does not show clinical evidence of testicular torsion, a urinalysis and culture may help exclude urinary tract infection and epididymitis as the etiology of the scrotal complaints.

Urinalysis results are usually normal in testicular torsion. 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 the presence of WBCs to exclude the diagnosis.

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Blood Studies

The complete blood count can be normal. However, the WBC count is elevated in as many as 60% of patients who have torsion.

Elevation in acute-phase proteins (ie, C-reactive protein) has been postulated as a diagnostic aid in differentiating inflammatory causes of acute scrotal pain (eg, epididymitis) from noninflammatory causes (eg, testicular torsion).[19] However, sample sizes in these studies have been too small to support using CRP as a diagnostic adjunct to definitively rule out testicular torsion.

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Ultrasonography

Testicular torsion is a clinical diagnosis. If the history and physical examination strongly suggest testicular torsion, the patient should go directly to surgery without delaying to perform imaging studies.

When a low suspicion of testicular torsion exists, color Doppler and power Doppler ultrasonography can be used to demonstrate arterial blood flow to the testicle while providing information about scrotal anatomy and other testicular disorders. (For images, see Testicular Torsion Imaging.)

Plain Doppler ultrasonography is less accurate than color Doppler in assessing testicular blood flow. In fact, early in the course of testicular torsion, gray-scale ultrasonographic examination may be absolutely normal.

Ultrasonographic findings suggestive of acute testicular torsion include the following[20] :

  • Absent or decreased blood flow in the affected testicle
  • Decreased flow velocity in the intratesticular arteries
  • Increased resistive indices in the intratesticular arteries
  • Hypervascularity with a low resistance flow pattern (after partial torsion-detorsion)

The sensitivity of color Doppler examination with newer ultrasonography equipment in detecting acute testicular torsion in children is 90-100%, with the specificity of technically adequate studies being essentially 100%.[13] Other studies have suggested that color Doppler ultrasonography was only 86% sensitive, 100% specific, and 97% accurate in the diagnosis of torsion and ischemia in the painful scrotum.[21]

A 3-year study demonstrated that Doppler ultrasonography had 94% sensitivity, 96% specificity, 95.5% accuracy, 89.4% positive predictive value, and 98% negative predictive value.[22]

The detection of a color or power Doppler signal in a patient presenting with the clinical findings suggestive of testicular torsion does not absolutely exclude torsion. Clinical correlation should be incorporated in the evaluation of acute scrotum because color Doppler ultrasonography is not 100% sensitive.[23]

Spectral and color flow Doppler sonography has also been used to evaluate for partial testicular torsion. Variability of the Doppler waveform when compared with the contralateral testicle and reversal of diastolic blood flow are indirect clues that aid in the diagnosis of partial testicular torsion.[24]

Some smaller studies have evaluated the accuracy of emergency medicine physicians in performing bedside ultrasonography to evaluate for testicular torsion. While these studies have had generally favorable outcomes, diagnostic accuracy is always operator and institution dependent.[25, 26]

A study of the use of contrast-enhanced ultrasonography demonstrated no advantage of this modality over Doppler ultrasonography in the evaluation of the acute scrotum. Contrast-enhanced ultrasonography can, however, be used as a supplement to traditional Doppler sonography when the diagnosis is uncertain and following appropriate clinical and radiographic evaluation.[27]

In a study of 104 adolescent boys, Boettcher et al found that ultrasound predictors alone were not able to identify all cases of testicular torsion. However, clinical features (pain lasting less than 24 hours, nausea and/or vomiting, abnormal cremasteric reflex, and high position of the testis) were predictive with no false positives reported, thus reducing the negative exploration rate by over 55%. Because scrotal ultrasonography is unpleasant in these cases, Boettcher and colleagues recommend that the procedure be used for diagnosis only in patients who lack the clinical features of testicular torsion.[28]

In a study of 342 patients who presented to the emergency department with acute scrotum pain, Liang and colleagues reported no false-negative findings but a 2.6 % false-positive rate on ultrasounds performed to assess for testicular torsion. High rates of the clinical features of sudden-onset scrotal pain (88%), abnormal position of testis (86%), and absent cremasteric reflex (91%) were also reported in the patients with testicular torsion. The investigators concluded that color Doppler ultrasound was accurate and sensitive for diagnosis of torsion.z[29]

Altinkilic et al provided further evidence that routine surgical exploration is unnecessary in patients with symptoms of testicular torsion and a normal color-coded duplex sonography. In their prospective study of 236 patients with clinical suspicion of testicular torsion, the sensitivity, specificity, and positive and negative predictive values of color coded duplex sonography were 100%, 75.2%, 80.4%, and 100%, respectively.[30]

In a review of 155 surgical explorations for acute scrotal pain, Nason el al reported rates of 96.9%, 88.9%, 96.9% and 89% for sensitivity, specificity, and positive predictive value and negative predictive value, respectively, for Doppler ultrasound used to assess testicular torsion.[31]

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Magnetic Resonance Imaging

Small studies to date suggest that magnetic resonance imaging (MRI), particularly when performed with contrast enhancement, is highly accurate in the diagnosis of testicular torsion, particularly when torsion knot or whirlpool patterns are evident.

Dynamic contrast-enhanced MRI has also demonstrated accuracy.[32] The clinical utility of these studies, however, remains to be elucidated.

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Radionuclide Scans

If the diagnosis is equivocal, radionuclide scan of the testicles can be helpful to assess blood flow and to differentiate torsion from other conditions. (For images, see Testicular Torsion Imaging.) These studies should preferably be ordered once urologic consultation has been completed and only for equivocal presentations.

Scan results are abnormal in torsion when they demonstrate 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.

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Near-Infrared Spectroscopy

Near-infrared spectroscopy (NIRS) is an emerging tool to assess testicular torsion. It can measure oxygen saturation 3-4 cm deep in the skin, is rapid (lasting 20 seconds), and is noninvasive. Aydogdu et al performed a small prospective study evaluating 16 adult patients with testicular torsion and found NIRS to be 100% sensitive and specific for torsion when compared with the contralateral testis. More studies are needed confirmation before this modality becomes available for clinical use.[33]

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Contributor Information and Disclosures
Author

Oreoluwa I Ogunyemi, MD Resident Physician, Department of Urology, University of Wisconsin Hospitals and Clinics

Oreoluwa I Ogunyemi, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Urological Association, National Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

E Jason Abel, MD Assistant Professor of Urologic Oncology, Department of Urology, University of Wisconsin Hospital and Clinics, University of Wisconsin School of Medicine and Public Health; Attending Urologist, William S Middleton Memorial Veterans Hospital

Disclosure: Nothing to disclose.

Madelyn Weiker University of Wisconsin School of Medicine and Public Health

Madelyn Weiker is a member of the following medical societies: American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Leslie Tackett McQuiston, MD, FAAP Assistant Professor of Surgery (Urology) Dartmouth Medical School; Staff Pediatric Urologist, Dartmouth-Hitchcock Hospital

Leslie Tackett McQuiston, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and American Urological Association

Disclosure: Nothing to disclose.

Eugene Minevich, MD Assistant Professor, Department of Surgery, Division of Pediatric Urology, University of Cincinnati

Eugene Minevich, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association

Disclosure: Nothing to disclose.

Raymond Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation

Raymond Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Ta A, D'Arcy FT, Hoag N, D'Arcy JP, Lawrentschuk N. Testicular torsion and the acute scrotum: current emergency management. Eur J Emerg Med. 2015 Aug 11. 37-41. [Medline].

  2. Barthold JS. Abnormalities of the Testis and Scrotum and their Surgical Management. McDougal WS, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell- Walsh Urology. 10th ed. Philadelphia, PA: WB Saunders; 2012. 642-5.

  3. Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. 2004 Mar. 42(2):349-63. [Medline].

  4. Roth CC, Mingin GC, Ortenberg J. Salvage of bilateral asynchronous perinatal testicular torsion. J Urol. 2011 Jun. 185(6 Suppl):2464-8. [Medline].

  5. Kar A, Ozden E, Yakupoglu YK, Kefeli M, Sarikaya S, Yilmaz AF. Experimental unilateral spermatic cord torsion: the effect of polypolymerase enzyme inhibitor on histopathological and biochemical changes in the early and late periods in the ipsilateral and contralateral testicles. Urology. 2010 Aug. 76(2):507.e1-5. [Medline].

  6. Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. 2010 Sep. 28(7):786-9. [Medline].

  7. Cubillos J, Palmer JS, Friedman SC, Freyle J, Lowe FC, Palmer LS. Familial testicular torsion. J Urol. 2011 Jun. 185(6 Suppl):2469-72. [Medline].

  8. Cost NG, Bush NC, Barber TD, Huang R, Baker LA. Pediatric testicular torsion: demographics of national orchiopexy versus orchiectomy rates. J Urol. 2011 Jun. 185(6 Suppl):2459-63. [Medline].

  9. Cattolica EV, Karol JB, Rankin KN, Klein RS. High testicular salvage rate in torsion of the spermatic cord. J Urol. 1982 Jul. 128(1):66-8. [Medline].

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

  11. Sun J, Liu GH, Zhao HT, Shi CR. Long-term influence of prepubertal testicular torsion on spermatogenesis. Urol Int. 2006. 77(3):275-8. [Medline].

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

  13. Coley BD. The Acute Pediatric Scrotum. Ultrasound Clinics. 2006. 1:485-96. [Full Text].

  14. Yang C Jr, Song B, Liu X, Wei GH, Lin T, He DW. Acute scrotum in children: an 18-year retrospective study. Pediatr Emerg Care. 2011 Apr. 27(4):270-4. [Medline].

  15. Johnston BI, Wiener JS. Intermittent testicular torsion. BJU Int. 2005 May. 95(7):933-4. [Medline].

  16. Hayn MH, Herz DB, Bellinger MF, Schneck FX. Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction. J Urol. 2008 Oct. 180(4 Suppl):1729-32. [Medline].

  17. Creagh TA, McDermott TE, McLean PA, Walsh A. Intermittent torsion of the testis. BMJ. 1988 Aug 20-27. 297(6647):525-6. [Medline]. [Full Text].

  18. Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?. J Fam Pract. 2009 Aug. 58(8):433-4. [Medline].

  19. Doehn C, Fornara P, Kausch I, Büttner H, Friedrich HJ, Jocham D. Value of acute-phase proteins in the differential diagnosis of acute scrotum. Eur Urol. 2001 Feb. 39(2):215-21. [Medline].

  20. Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging. 2009 Sep-Oct. 34(5):648-61. [Medline].

  21. Dogra VS, Bhatt S, Rubens DJ. Sonographic Evaluation of Testicular Torsion. Ultrasound Clinics. 2006. 1:55-66.

  22. Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010 Jan. 29(1):11-21. [Medline].

  23. Turgut AT, Bhatt S, Dogra VS. Acute Painful Scrotum. Ultrasound Clinics. 2008. 3:93-107.

  24. Cassar S, Bhatt S, Paltiel HJ, Dogra VS. Role of spectral Doppler sonography in the evaluation of partial testicular torsion. J Ultrasound Med. 2008 Nov. 27(11):1629-38. [Medline].

  25. Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med. 2001 Jan. 8(1):90-3. [Medline].

  26. Bomann JS, Moore C. Bedside ultrasound of a painful testicle: before and after manual detorsion by an emergency physician. Acad Emerg Med. 2009 Apr. 16(4):366. [Medline].

  27. Moschouris H, Stamatiou K, Lampropoulou E, Kalikis D, Matsaidonis D. Imaging of the acute scrotum: is there a place for contrast-enhanced ultrasonography?. Int Braz J Urol. 2009 Nov-Dec. 35(6):692-702; discussion 702-5. [Medline].

  28. Boettcher M, Krebs T, Bergholz R, Wenke K, Aronson D, Reinshagen K. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int. 2013 Dec. 112(8):1201-6. [Medline].

  29. Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam Physician. 2014 May 1. 89(9):723-7. [Medline].

  30. Altinkilic B, Pilatz A, Weidner W. Detection of normal intratesticular perfusion using color coded duplex sonography obviates need for scrotal exploration in patients with suspected testicular torsion. J Urol. 2013 May. 189(5):1853-8. [Medline].

  31. Nason GJ, Tareen F, McLoughlin D, McDowell D, Cianci F, Mortell A. Scrotal exploration for acute scrotal pain: a 10-year experience in two tertiary referral paediatric units. Scand J Urol. 2013 Oct. 47(5):418-22. [Medline].

  32. Terai A, Yoshimura K, Ichioka K, Ueda N, Utsunomiya N, Kohei N, et al. Dynamic contrast-enhanced subtraction magnetic resonance imaging in diagnostics of testicular torsion. Urology. 2006 Jun. 67(6):1278-82. [Medline].

  33. Burgu B, Aydogdu O, Huang R, Soygur T, Yaman O, Baker L. Pilot Feasibility Study of Transscrotal Near Infrared Spectroscopy in the Evaluation of Adult Acute Scrotum. J Urol. 2013 Jan 29. [Medline].

  34. 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].

  35. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15. 88(12):835-40. [Medline].

  36. Güneş M, Umul M, Çelik AO, Armağan HH, Değirmenci B. A novel approach for manual de-torsion of an atypical (outward) testicular torsion with bedside Doppler ultrasonography guidance. Can Urol Assoc J. 2015 Sep-Oct. 9 (9-10):E676-8. [Medline]. [Full Text].

  37. Park K, Choi H. An evolution of orchiopexy: historical aspect. Korean J Urol. 2010 Mar. 51(3):155-60. [Medline]. [Full Text].

  38. Dajusta DG, Granberg CF, Villanueva C, Baker LA. Contemporary review of testicular torsion: New concepts, emerging technologies and potential therapeutics. J Pediatr Urol. 2012 Oct 5. [Medline]. [Full Text].

  39. Lian BS, Ong CC, Chiang LW, Rai R, Nah SA. Factors Predicting Testicular Atrophy after Testicular Salvage following Torsion. Eur J Pediatr Surg. 2015 Oct 28. [Medline].

  40. Kozminski DJ, Kraft KH, Bloom DA. Orchiopexy without Transparenchymal Fixation Suturing: A 29-Year Experience. J Urol. 2015 Dec. 194 (6):1743-7. [Medline].

  41. Liang T, Metcalfe P, Sevcik W, Noga M. Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum. AJR Am J Roentgenol. 2013 May. 200(5):W444-9. [Medline].

 
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Testicular torsion: (A) extravaginal; (B) intravaginal.
A 17-year-old adolescent boy with a 72-hour history of scrotal pain.
Intraoperative findings in testicular torsion.
Transverse power Doppler image of both testes illustrates an enlarged, avascular left testicle.
Testicular torsion. Transverse color Doppler image of the left groin illustrates an undescended testicle without flow.
 
 
 
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