Testicular Torsion Treatment & Management

Manual detorsion of the torsed testis may be attempted but is usually difficult because of acute pain during manipulation. This nonoperative detorsion is not a substitute for surgical exploration. If successful (ie, confirmed by color Doppler sonogram in a patient with complete resolution of symptoms), perform definitive surgical fixation of the testes before the patient leaves the hospital as an urgent—rather than emergent—procedure.

A recent study has shown that the use of nicotinamide may successfully decrease ischemia-reperfusion injury in early and late periods in both testicles.^[2]

Treatment of testicular torsion varies according to patient age.

• Treat patients who are born with testicular torsion by performing early elective exploration and contralateral orchidopexy (anchoring) because bilateral (synchronous or asynchronous) neonatal testicular torsion is described.
• The potential for salvage of such a testis is nil, making the risk of immediate surgery before complete stabilization of the newborn unwarranted.
• In distinct contrast, a newborn with a normal testis at birth who subsequently undergoes torsion requires immediate exploration.
• Perform the operation through the midline scrotal raphe.
• Enter the ipsilateral scrotal compartment; then, deliver and untwist the testis.
• Evaluate the testis for viability.
• Remove the necrotic testis to avoid prolonged, debilitating pain and tenderness. Retention of a necrotic testis may exacerbate the potential for subfertility, presumably because of development of an autoimmune phenomenon.
• To prevent subsequent torsion, fix viable gonads to the scrotal wall with 3-4 nonabsorbable sutures. Perform both exploration and anchoring of the contralateral testis through the same incision.

Signs of a viable testis after detorsion (see image below) include a return of color, return of Doppler flow, and arterial bleeding after incision of tunica albuginea.

• Testicular prosthesis placement

  • Patients requiring an orchiectomy because of a nonviable testis may benefit from the placement of a testicular prosthesis.
  • Delay this placement, usually for 6 months, until healing is complete and inflammatory changes resolve.
  • Perform the prosthetic placement through an inguinal incision.

Torsion of the spermatic cord continues to be one of the few emergencies in urologic practice. Delay of more than 6-8 hours between onset of symptoms and the time of surgical (or manual) detorsion reduces the salvage rate to 55-85%. A correlation may exist between the duration of torsion and abnormal semen parameters, and some authorities suggest that retention of an injured testis can induce pathologic changes to the contralateral testis.

Success in the management of spermatic cord torsion is measured by immediate testicular salvage and incidence of late testicular atrophy, which are, in turn, directly related to the duration and degree of testicular torsion. Delaying surgical intervention worsens the intraoperative testicular salvage and incidence rate and the extent of subsequent testicular atrophy. The delay between the onset of symptoms and the time of surgical or manual detorsion is obviously of utmost importance in achieving a viable testis.

Recent studies show that exocrine and endocrine function is substandard in men with a history of unilateral torsion. The following 3 theories explain the contralateral disease noted in torsion:

• Unrecognized or unreported repeated injury to both testes
• Preexisting pathologic condition predisposing to both abnormal spermatogenesis and torsion of the spermatic cord^[3]
• Induction of pathologic changes in the contralateral testis by retention of the injured testis

To explain the decreased fertility observed in unilateral torsion of the spermatic cord, several specialists suggest an autoimmune mechanism. This hypothesis is based upon the following:

• Knowledge of the blood-testis barrier, which isolates the luminal compartment of the seminiferous tubule
• Inducing experimental allergic orchitis
• Likening contralateral testicular disease to sympathetic ophthalmia, a cell-mediated immune response