Testicular Torsion in Emergency Medicine 

  • Author: Timothy J Rupp, MD, FACEP, FAAEM; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Aug 8, 2011
 

Overview

Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle.[1] Though testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most frequent cause of testicle loss in that population.

In pediatric patients, the following features are associated with higher likelihood of torsion[2] :

  • Pain duration of less than 24 hours
  • Nausea or vomiting
  • High position of the testicle
  • Abnormal cremasteric reflex

Results of physical examination are imperfect in ruling out testicular torsion, however.[3] Imaging studies (eg, ultrasonography, nuclear scans) may be useful when a low suspicion of testicular torsion exists.[4, 5, 6, 7, 8, 9, 10] A Doppler sonogram of an avascular testicle is shown below. Surgical exploration should not be delayed for the sake of performing imaging studies.

Transverse power Doppler image of both testes illuTransverse power Doppler image of both testes illustrates an enlarged, avascular left testicle.

If the diagnosis of torsion is suspected on clinical grounds, early urologic consultation is mandatory since definitive treatment is surgery for detorsion and orchiopexy or possible orchiectomy. Transfer the patient if no urologist is available. Administer analgesic medication, as testicular torsion is typically very painful.

For other discussions of this condition, see the Medscape Reference articles Testicular Torsion and Pediatric Testicular Torsion.

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Manual Detorsion

The procedure for manual detorsion of the testis is similar to the "opening of a book" when the physician is standing at the patient's feet. Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting outward and laterally. Lateral rotation has been described in up to a third of testicular torsions, however,[8, 9] and in such cases further lateral rotation will worsen the condition.

For manual detorsion in a suspected torsion of the right testicle, the physician is positioned in front of the standing or supine patient and holds the patient's right testicle with the left thumb and forefinger. The physician then rotates the right testicle outward 180° in a medial-to-lateral direction. For the patient's left testicle, the physician uses the right thumb and forefinger and rotates the patient's left testicle in an outward direction 180° from medial to lateral.

Rotation of the testicle may need to be repeated 2-3 times for complete detorsion. Pain relief serves as a guide to successful detorsion, but restoration of blood flow must be confirmed following the maneuver.[11] Subsequent elective orchiopexy is recommended, to prevent recurrent torsion.[12]

In the literature, the success rate of manual detorsion has varied widely. Success rates have ranged from 26.5% to more than 80%.[12]

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Contributor Information and Disclosures
Author

Timothy J Rupp, MD, FACEP, FAAEM  Associate Medical Director, Physicians Emergency Care Associates, Methodist Health System; Clinical Physician, Children's Medical Center of Dallas and Children's Medical Center at Legacy, Plano; Clincal Associate Professor, University of Texas Southwestern Medical Center at Dallas

Timothy J Rupp, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of 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: Nothing to disclose.

Specialty Editor Board

Richard S Krause, MD  Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

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.

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

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.

Chief Editor

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References

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

  2. 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. Sep 2010;28(7):786-9. [Medline].

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

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

  5. 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].

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

  7. 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. Jan 2010;29(1):11-21. [Medline].

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

  9. 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].

  10. 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].

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

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

  13. 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].

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

 
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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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