eMedicine Specialties > Emergency Medicine > Genitourinary
Testicular Torsion: Treatment & Medication
Updated: Oct 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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.
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
Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway with uncertain rapid airway control; respiratory depression; nausea; emesis; constipation; urinary retention
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.
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
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
Documented hypersensitivity
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.
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
Phenothiazines, barbiturates, alcohols, and MAO inhibitors increase CNS toxicity when administered concurrently
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)
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)
More on Testicular Torsion |
| Overview: Testicular Torsion |
| Differential Diagnoses & Workup: Testicular Torsion |
 Treatment & Medication: Testicular Torsion |
| Follow-up: Testicular Torsion |
| Multimedia: Testicular Torsion |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
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
