eMedicine Specialties > Emergency Medicine > Genitourinary

Testicular Torsion

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
Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University

Updated: Oct 27, 2009

Introduction

Background

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. Though testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males, and testicular torsion is the most frequent cause of testicle loss in that population.

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

Pathophysiology

The testicle is covered by the tunica vaginalis, a potential space that encompasses the anterior two thirds of the testicle and where fluid from a variety of sources may accumulate. The tunica vaginalis attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum.

In patients who have an inappropriately high attachment of the tunica vaginalis, the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly, called the bell clapper deformity, can result in the long axis of the testicle being oriented transversely rather than cephalocaudal. This congenital abnormality is present in approximately 12% of males, 40% of whom have the abnormality in the contralateral testicle as well.¹ The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord. Torsion occurs as the testicle rotates between 90° to 1080° causing compromised blood flow to the testicle.

Complete torsion usually occurs when the testicle twists 360° or more and incomplete or partial torsion when the twisting is less than this. The twisting causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle. How tightly the testicle is twisted and how many turns seem to correlate with how quickly the testicle becomes nonviable from ischemia.

In the neonatal age group, the testicle frequently has not yet descended into the scrotum, where it becomes attached within the tunica vaginalis. This mobility of the testicle predisposes it to torsion (extravaginal testicular torsion). Inadequate fusion of the testicle to the scrotal wall typically occurs within the first 7-10 days of life.

Frequency

United States

Incidence of torsion in males younger than 25 years is approximately 1 in 4000.² Torsion more often involves the left testicle.

Of the cases of testicular torsion that occur in the neonatal population, 70% occur prenatally and 30% occur postnatally.

Mortality/Morbidity

This urologic emergency requires prompt diagnosis, immediate urologic consultation, and rapid definitive operative treatment for salvage of the testicle.

A salvage rate of 90-100% is found in patients who undergo detorsion within 6 hours of pain; the viability rate fell to between 20% and 50% after 12 hours; and 0 to 10% viability if detorsion is delayed greater than 24 hours.^3,2

Sex

Testicular torsion affects males only.

Age

Testicular torsion most often is observed in males younger than 30 years, with most aged 12-18 years. The peak age is 14 years, although a smaller peak also occurs during the first year of life.

Clinical

History

• History includes a sudden onset of severe unilateral scrotal pain.
• Onset of pain can occur more slowly, but this is an uncommon presentation of torsion.
• Torsion can occur with activity, can be related to trauma in 4-8% of cases,² or can develop during sleep.
• The historical features suggestive of testicular torsion include the following:
  • Acute onset of unilateral scrotal pain
  • Scrotal swelling
  • Nausea and vomiting: In the pediatric population, nausea and vomiting more commonly accompany acute testicular torsion and have a positive predictive value of greater than 96%.⁴
  • Abdominal pain (20-30%)
  • Fever (16%)
  • Urinary frequency (4%)
• Many patients have a history of recurrent scrotal pain that has resolved spontaneously. This history is highly suggestive of intermittent torsion and detorsion of the testicle. Patients who complain of what sounds like torsion-detorsion should be referred promptly to a urologist since patients with symptoms of intermittent torsion who electively have surgical exploration are less likely to develop subsequent torsion and loss of the testicle.⁵ Creagh et al reported that acute torsion developed in 10% of patients with intermittent torsion while they waited for surgery.⁶

Physical

• The physical examination may be difficult to perform, particularly in the case of an ill child.
• Involved testicle painful to palpation; frequently elevated in position when compared with the other side
• Horizontal lie of the testicle
• Enlargement and edema of the testicle; edema involving the entire scrotum
• Scrotal erythema
• Ipsilateral loss of the cremasteric reflex - The cremasteric reflex is almost always absent in patients with testicular torsion, and its presence may help to distinguish other causes of acute scrotal pain from testicular torsion.^7,8
• Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign])
• Fever (uncommon)

Causes

• Congenital anomaly; bell clapper deformity
• Undescended testicle
• Sexual arousal and/or activity
• Trauma
• Increase in testicular volume
• Testicular tumor
• Exercise
• Active cremasteric reflex
• Cold weather

Differential Diagnoses

Other Problems to Be Considered

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

Workup

Laboratory Studies

• 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
  • The hospital's radiology department usually provides ultrasound services. 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.

Treatment

Emergency Department Care

• Early diagnosis and prompt urologic consultation is essential since time is critical in salvage of the testicle.
• Mild analgesic pain relief can be administered once testicular torsion has been considered, while awaiting urologic consultant, or while awaiting further studies.
• Some consultants prefer no analgesics be administered so that their examination is not biased. Emergency Medicine literature supports judicious administration of analgesics to allow for a more accurate physical examination. Overadministration of analgesics may indeed compromise the clinician's physical examination.
• Attempt manual detorsion with pain relief as the guide for successful detorsion. The procedure 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 mid line; thus, manual detorsion of the testicle involves twisting outward and laterally.
  • For example, in a suspected torsion of the right testicle, the physician is 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.
  • Rotation of the testicle may need to be repeated 2-3 times for complete detorsion and to provide pain relief to the patient.
  • 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.
  • Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of reviewed studies.²

Consultations

If the clinical diagnosis of torsion is suspected, early urologic consultation is mandatory since definitive treatment is surgery for detorsion and orchiopexy or possible orchiectomy.

Medication

Administer pain relief judiciously and cautiously after the diagnosis of testicular torsion is made. Some urologists prefer no analgesics be administered so their evaluation and examination of the patient are not prejudiced.

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have sustained painful trauma.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h

Pediatric

Neonates: 0.05-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose
Children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs, MAOIs, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway with uncertain rapid airway control; respiratory depression; nausea; emesis; constipation; urinary retention

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Antiemetic, Serotonin Antagonists

These agents are used to prevent nausea and vomiting.

Ondansetron (Zofran)

Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally. Prevents nausea and vomiting associated with emetogenic cancer chemotherapy (eg, high-dose cisplatin), and complete body radiotherapy.

Dosing

Adult

4 mg IV or PO (orally disintegrating tablet) q4-6h prn nausea and vomiting

Pediatric

6 months to 18 years: 0.15 mg/kg IV q4-6h prn nausea and vomiting
Orally disintegrating tablet: 4 mg PO q4-6h prn nausea and vomiting

Interactions

Although there is potential for cytochrome P-450 inducers (barbiturates, rifampin, carbamazepine, and phenytoin) to change half-life and clearance of ondansetron, dosage adjustment is not usually required

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause headache

Antianxiety Agent

These agents are used to reduce anxiety.

Diazepam (Diastat, Diazemuls, Valium)

Modulates postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition. Appears to act on part of the limbic system, the thalamus, and hypothalamus, to induce a calming effect. Also has been found to be an effective adjunct for the relief of skeletal muscle spasm caused by upper motor neuron disorders.

Rapidly distributes to other body fat stores. Twenty minutes after initial IV infusion, serum concentration drops to 20% of Cmax.

Individualize dosage and increase cautiously to avoid adverse effects.

Dosing

Adult

2-10 mg PO/IM/IV q3-4h, repeat q2-4h prn; not to exceed 30 mg in 8 h

Pediatric

0.05-0.3 mg/kg/dose IV over 2-3 min or IM; repeat in 2-4 h prn
Alternatively, 0.12-0.8 mg/kg/d PO divided q6-8h; not to exceed 10 mg/dose

Interactions

Phenothiazines, barbiturates, alcohols, and MAO inhibitors increase CNS toxicity when administered concurrently

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; reversal agents (eg, flumazenil) contraindicated when lorazepam used for life-threatening conditions (eg, control of intracranial pressure or status epilepticus)

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)

Follow-up

Transfer

• Transfer the patient if no urologist is available.

Complications

Complications of testicular torsion may include the following:

• Infarction of testicle
• Loss of testicle
• Infection
• Infertility secondary to loss of testicle
• Cosmetic deformity

Prognosis

• If testicular torsion is diagnosed early, a near 100% salvage rate for the testicle is possible. Orchiopexy is not a guarantee against future torsion, though it does reduce the odds of a future torsion.

Patient Education

• For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education article Testicular Pain.

Miscellaneous

Medicolegal Pitfalls

• Failure to recognize a urologic emergency
• Delay in obtaining urologic consultation
• Misdiagnosing as epididymitis
• Partial reduction of a torsion (ie, 720°)

Multimedia

Media file 1: Transverse power Doppler image of both testes illustrates an enlarged, avascular left testicle.

Media file 2: Testicular torsion. Transverse color Doppler image of the left groin illustrates an undescended testicle without flow.

References

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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].

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

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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

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: Medicines Company Consulting fee Consulting; 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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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