Testicular torsion results from abnormal fixation of the testis within the tunica vaginalis, allowing the testis to twist. It exhibits a bimodal age distribution, peaking in the perinatal period and during puberty but may occur at any age. Although sometimes associated with trauma, torsion usually occurs in the absence of any preceding event.
Because of the potential for infarction and infertility, testicular torsion must be the primary consideration in any male complaining of testicular pain. Pain usually occurs suddenly, is severe, and is felt in the lower abdominal quadrant, the inguinal canal, or the testis. The pain may be constant or intermittent but is not positional because torsion is primarily an ischemic event. Although symptom onset tends to occur after exertion, the testicle also may twist from unilateral cremasteric muscle contraction during sleep. Early in presentation, the affected testicle is firm, tender, elevated, and in a transverse lie compared to the contralateral testicle. The unilateral absence of the cremasteric reflex is a sensitive but nonspecific finding.
Diagnosis and Differential
Color-flow duplex ultrasound is the most commonly used confirmatory study, but sensitivity ranges from 69% to 90%. In addition, urinalysis is typically ordered, but pyuria does not rule out testicular torsion.
Torsion of the appendages is more common than testicular torsion but is not dangerous because the appendix testis and appendix epididymis have no known function. The diagnosis is supported by pain that is most intense near the head of the epididymis or testis, an isolated tender nodule, or the pathognomonic blue dot appearance of a cyanotic appendage with illumination through thin prepubertal scrotal skin. If normal intratesticular blood flow can be demonstrated with color Doppler, surgical exploration is not necessary because most appendages calcify or degenerate over 10 to 14 days and cause no harm. The differential for testicular torsion also includes epididymitis, inguinal hernia, hydrocele, and scrotal hematoma.
Emergency Department Care and Disposition
When the diagnosis of testicular torsion is obvious, immediate urologic consultation is indicated for exploration because imaging tests can be too time consuming. Testicular salvage rates are excellent with surgical detorsion within 6 hours of symptom onset, but decline rapidly thereafter.
The emergency physician can attempt manual detorsion. Most testes twist in a lateral to medial direction, so detorsion is performed in a medial to lateral direction, similar to the opening of a book. The endpoint for successful detorsion is pain relief; urologic referral is still indicated.
Urology should be consulted early in the patient's course even if confirmatory testing is planned. When the diagnosis of testicular torsion cannot be ruled out by diagnostic studies or examination, urologic consultation is still indicated if suspicion is high.
EPIDIDYMITIS AND ORCHITIS
Epididymitis is characterized by gradual onset of pain due ...