Manual Detorsion

During initial examination, manual detorsion may be attempted. This is done by elevating the testis toward the ipsilateral inguinal ring, stabilizing the cranial portion of the spermatic cord, and rotating the testis laterally. If successful, there will be a lengthening of the spermatic cord and immediate relief of pain. Should the first attempt be unsuccessful, a second attempt could be made using medial rotation of the testis. A study of rotational direction found that 46% of torsions (38 of 81 patients) were laterally rotated.^[43]In a series of patients undergoing attempted detorsion, testis salvage was higher in those patients that had successful manual detorsion.^[44]Regardless of the outcome of manual detorsion, surgical exploration and testicular fixation should be performed prior to the patient being discharged from the hospital.^[1]

Success of manual detorsion can be assessed with the use of Doppler sonography and resolution of symptoms.^[45]

Surgical Detorsion

Surgical detorsion and subsequent orchiopexy or orchiectomy is the definitive management strategy and should proceed immediately in patients whose clinical findings suggest torsion. The patient and/or caregiver should be counseled on the risk of immediate or delayed testicular loss. Additionally, they should be advised that the impact of torsion on later fertility, even if testicular salvage occurs, cannot be assured.

Extravaginal torsion

In newborns presenting with torsion at birth, the timing of surgical exploration remains controversial, since testicular salvage rates are low and anesthetic risk is increased. Additionally, asynchronous torsion remains uncommon (11.8%).^{[46, 47]}Despite those concerns, most of the literature supports immediate exploration and fixation of the contralateral testis to prevent the potential devastating outcome of asynchronous testis loss.^{[48, 47]}

Intravaginal torsion

Immediate surgical exploration with detorsion and orchiopexy or orchiectomy is the recommended and accepted management strategy for males presenting with clinical signs of testis torsion. Surgical exploration should not be delayed to obtain confirmatory radiologic studies in patients who present with suggestive clinical signs of torsion.

The surgical approach is through a midline longitudinal, or bilateral transverse scrotal incision. On entry into the affected hemi-scrotum, the surgeon should perform immediate detorsion of the affected testis, while noting color, degree of torsion, and anatomy of the tunica vaginalis.

After the testis is untwisted, it is wrapped in warm wet gauze. Exploration of the contralateral hemiscrotum and orchiopexy of the unaffected testis is then performed to reduce the risk of asynchronous torsion. The affected testis is re-examined for viability. If blood flow remains questionable, intraoperative Doppler can be utilized, or an incision can be made into the tunica albuginea. If the testis appears viable, orchiopexy is performed. If the decision is made to perform orchiectomy, a prosthesis can be placed at this time, but insertion is often deferred for the nonacute setting.^[5]

Intravaginal torsion in a child.

View Media Gallery

Medication

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Media Gallery

Testicular torsion: (A) extravaginal; (B) intravaginal.
A 17-year-old adolescent boy with a 72-hour history of scrotal pain.
Intraoperative findings in testicular torsion.
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.
Example of scrotal appearance in testicular torsion.
Extravaginal torsion in a newborn.
Intravaginal torsion in a child.

of 8

Author

Ranjiv I Mathews, MD Professor of Urology and Pediatrics, Director of Pediatric Urology, Director of Urology Residency Program, Division of Urology, Department of Surgery, Southern Illinois University School of Medicine

Ranjiv I Mathews, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Illinois State Medical Society, Illinois Urological Society, Indian American Urological Association, North Central Section of the American Urological Association (AUA), Society for Fetal Urology, Society for Pediatric Urology

Disclosure: Nothing to disclose.

Coauthor(s)

Roberta Koeppen, MD Resident Physician, Department of Urology, Southern Illinois University School of Medicine

Roberta Koeppen, MD is a member of the following medical societies: American Medical Association, American Urological Association, Phi Theta Kappa, Sexual Medicine Society of North America

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

Additional Contributors

E Jason Abel, MD Associate Professor of Urologic Oncology, Department of Urology, Associate Professor of Radiology (Affiliate Appointment), Department of Radiology, University of Wisconsin School of Medicine and Public Health; Attending Urologist, William S Middleton Memorial Veterans Hospital

E Jason Abel, MD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, American Urological Association, Harris County Medical Society, Kidney Cancer Association, Society for Basic Urologic Research, Society of Urologic Oncology, Texas Medical Association

Disclosure: Nothing to disclose.

Oreoluwa I Ogunyemi, MD Resident Physician, Department of Urology, University of Wisconsin Hospitals and Clinics

Oreoluwa I Ogunyemi, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Urological Association, National Medical Association

Disclosure: Nothing to disclose.

Madelyn Weiker University of Wisconsin School of Medicine and Public Health

Madelyn Weiker is a member of the following medical societies: American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Acknowledgements

Leslie Tackett McQuiston, MD, FAAP Assistant Professor of Surgery (Urology) Dartmouth Medical School; Staff Pediatric Urologist, Dartmouth-Hitchcock Hospital

Leslie Tackett McQuiston, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and American Urological Association

Disclosure: Nothing to disclose.

Eugene Minevich, MD Assistant Professor, Department of Surgery, Division of Pediatric Urology, University of Cincinnati

Eugene Minevich, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association

Disclosure: Nothing to disclose.

Raymond Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation

Raymond Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

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