Priapism. Aspiration of the corpora cavernosa followed by injection of α-adrenergic agents such as phenylephrine through the same needle is demonstrated by combining two syringes with a three-way stopcock. (Photo contributor: David Effron, MD.)
Young men (average age 16-17.5 years) complain of the sudden onset of pain in one testicle, followed by swelling of the affected testicle, reddening of the overlying scrotal skin, lower abdominal pain, nausea, and vomiting. An examination reveals a swollen, tender, retracted testicle that often lies in the horizontal plane (bell-clapper deformity). The spermatic cord is frequently swollen on the affected side. In delayed presentations, the entire hemiscrotum may be swollen, tender, and firm. The urine is usually clear with a normal urinalysis. In one-third of cases, there is a peripheral leukocytosis.
Management and Disposition
Obtain urologic consultation immediately and prepare to go to the operating room without delay. Doppler ultrasound or technetium scanning may be helpful if these procedures will not delay surgery. In the interim, detorsion may be attempted if the patient is seen within a few hours of onset: open the affected testicle like a book, that is, the right testicle turned counterclockwise when viewed from below and the left testicle turned clockwise. Pain relief is immediate. Decreased pain prompts additional turns (as many as three) to complete detorsion; increased pain prompts detorsion in the opposite direction. Do not delay operative intervention for ancillary studies since testicular infarction will occur within 6 to 12 hours after torsion.
The cremasteric reflex is almost always absent in testicular torsion.
Patients may report similar, less severe episodes that spontaneously resolved in the recent past.
Half of all torsions occur during sleep.
Abdominal or inguinal pain is sometimes present without pain to the scrotum.
The age of presentation has a bimodal pattern, since torsion is more prevalent during infancy and adolescence.
Testicular Torsion. Swollen, tender hemiscrotum, with erythema of scrotal skin and retracted testicle. (Photo contributor: Stephen W. Corbett, MD.)
Bell-Clapper Deformity. Twisting of the spermatic cord causes the testicle to be elevated with a horizontal lie. Lack of fixation to the posterior scrotum predisposes the freely movable testicles to rotation and subsequent torsion. Asymptomatic patients with bell-clapper deformity are at risk for torsion.
Testicular Torsion. A retracted testicle consistent with early testicular torsion (minimal edema) is seen in both of these patients. (A) (Photo contributor: David W. Munter, MD, MBA.) (B) (Photo contributor: Emergency Medicine Department, Naval Medical Center Portsmouth.)