eMedicine Specialties > Emergency Medicine > Genitourinary

Testicular Torsion: Differential Diagnoses & Workup

Author: Timothy J Rupp, MD, FACEP, Associate Medical Director, Physicians Emergency Care Associates, Methodist Health System, Dallas, Texas; Staff Physician, Innovative Emergency Medicine, Frisco, Texas; Staff Physician, Department of Emergency Medicine, Children's Medical Center of Dallas, Dallas, Texas
Coauthor(s): Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Contributor Information and Disclosures

Updated: Jan 8, 2010

Differential Diagnoses

Appendicitis, Acute
Pediatrics, Appendicitis
Epididymitis
Scrotal Trauma
Fournier Gangrene
Spermatocele
Henoch-Schonlein Purpura
Testicular Choriocarcinoma
Hernias
Testicular Seminoma
Hydrocele
Testicular Trauma
Idiopathic Testicular Infarction
Testicular Tumors: Nonseminomatous
Orchitis
Varicocele

Other Problems to Be Considered

Traumatic rupture
Traumatic hematoma
Torsion of testicular appendage (appendix testis)

Workup

Laboratory Studies

  • 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.
  • Urinalysis
    • Urinalysis result is usually normal.
    • 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 WBC presence to exclude the diagnosis.
  • Complete blood count: CBC can be normal or show an elevated WBC count in as many as 60% of patients who have torsion.
  • Acute-phase proteins (C-reactive protein [CRP]): Elevation in acute-phase proteins, namely the CRP, has been postulated as a diagnostic aid in differentiating inflammatory causes of acute scrotal pain (epididymitis) from noninflammatory causes (testicular torsion).9 However, sample sizes in these studies have been too small to definitively rule out testicular torsion using CRP as a diagnostic adjunct.

Imaging Studies

  • Testicular torsion is a clinical diagnosis. Imaging studies usually are not necessary; ordering them wastes valuable time when the definitive treatment is emergent urologic consultation for surgical management. If the history and physical examination strongly suggest testicular torsion, the patient should go directly to surgery without any delay to perform imaging studies.
  • If the diagnosis is equivocal, radionuclide scan of the testicles or ultrasonography can be helpful to assess blood flow and to differentiate torsion from other conditions. 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.
  • Color Doppler and power Doppler ultrasonography are used to demonstrate arterial blood flow to the testicle while providing information about scrotal anatomy and other testicular disorders. For images, see Testicular Torsion in the Radiology volume.
    • 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 absent or decreased blood flow in the affected testicle, decreased flow velocity in the intratesticular arteries, increased resistive indices in the intratesticular arteries, and hypervascularity with a low resistance flow pattern (after partial torsion-detorsion).10
    • 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%.4 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.11
    • The detection of 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 the acute painful scrotum because color Doppler ultrasonography is not 100% sensitive.12
    • Spectral and color flow Doppler sonography has also been used to evaluate for partial testicular torsion with variability of the Doppler waveform when compared with the contralateral testicle and reversal of diastolic blood flow being indirect clues that aid in the diagnosis of partial testicular torsion.13
    • Some smaller studies have evaluated emergency medicine physicians performing bedside ultrasonography to evaluate for testicular torsion. While these studies have had generally favorable outcomes, diagnostic accuracy is always operator and institution dependent.14
    • Near-infrared spectroscopy and dynamic contrast-enhanced magnetic resonance imaging demonstrated utility in the diagnosis of testicular torsion in experimental models;15,16 the clinical utility of these studies, however, remains to be elucidated.

More on Testicular Torsion

Overview: Testicular Torsion
Differential Diagnoses & Workup: Testicular Torsion
Treatment & Medication: Testicular Torsion
Follow-up: Testicular Torsion
Multimedia: Testicular Torsion
References
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References

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

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

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

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

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

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

  7. Brenner JS, Ojo A. Evaluation of scrotal pain or swelling in children and adolescents. UpToDate [web site]. 2006.

  8. Eyre RC. Evaluation of the acute scrotum in adults. UpToDate [web site].

  9. Doehn C, Fornara P, Kausch I, et al. Value of acute-phase proteins in the differential diagnosis of acute scrotum. Eur Urol. Feb 2001;39(2):215-21. [Medline].

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

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

  12. Turgut AT, Bhatt S, Dogra VS. Acute Painful Scrotum. Ultrasound Clinics. 2008;3:93-107. [Full Text].

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

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

  15. Capraro GA, Mader TJ, Coughlin BF, et al. Feasibility of using near-infrared spectroscopy to diagnose testicular torsion: an experimental study in sheep. Ann Emerg Med. Apr 2007;49(4):520-5. [Medline].

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

  17. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. Mar 2000;105(3 Pt 1):604-7. [Medline].

  18. Blank BH, Goldsmith G, Schneider RE. Recognizing a testicular emergency. Patient Care. 1997;31(13):117-35.

  19. Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate [web site]. 2006.

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

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

  22. Flanigan RC, DeKernion JB, Persky L. Acute scrotal pain and swelling in children: a surgical emergency. Urology. Jan 1981;17(1):51-3. [Medline].

  23. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. Jul 1998;102(1 Pt 1):73-6. [Medline].

  24. McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am. Nov 2003;21(4):909-35. [Medline].

  25. Schwab R. Acute scrotal pain requires quick thinking and plan of action. Emerg Med Rep. 1992;13(2):11-7.

  26. Wan J, Bloom DA. Genitourinary problems in adolescent males. Adolesc Med. Oct 2003;14(3):717-31, viii. [Medline].

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Further Reading

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Keywords

testicular torsion, testicular torsion symptoms, testicular torsion treatment, testicular torsion causes, testicular pain, scrotal pain, torsion of testis, torsion of the testes, testicle pain, severe unilateral scrotal pain, scrotal swelling, scrotal erythema, undescended testicle, testicular trauma

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Contributor Information and Disclosures

Author

Timothy J Rupp, MD, FACEP, Associate Medical Director, Physicians Emergency Care Associates, Methodist Health System, Dallas, Texas; Staff Physician, Innovative Emergency Medicine, Frisco, Texas; Staff Physician, Department of Emergency Medicine, Children's Medical Center of Dallas, Dallas, Texas
Timothy J Rupp, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Gay and Lesbian Medical Association, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Pfizer Salary Employment

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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