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.)
Testicular torsion is a twisting of the spermatic cord that leads to testicular ischemia and is a surgical emergency. This condition mainly affects neonates and adolescents, but can occur in older adults as well. Common symptoms include acute-onset testicular pain and swelling with an exam revealing a tender testicle lying in a horizontal plane (bell-clapper deformity). Nausea, vomiting, and abdominal pain may be present.
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, VA.)
Management and Disposition
If testicular torsion is suspected, obtain immediate urologic consultation. Ultrasound is diagnostic (unless intermittent torsion is present), but surgical management should not be delayed for confirmatory imaging as the time to operative intervention predicts testicular viability. Manual detorsion can be attempted if operative management is not immediately available. In roughly two-thirds of cases, testicular torsion occurs in the medial direction, so rotating the testicle away from the midline may temporarily improve blood flow. The common explanation of the maneuver is that of “opening a book” where the direction of rotation of the patient’s right testicle is counterclockwise when viewed from below and the left is clockwise.
Testicular Torsion. Swollen, tender scrotal mass. (Photo contributor: Patrick McKenna, MD.)
Testicular Torsion. A red, swollen hemiscrotum is seen in this right testicular torsion in a 14-year-old. (Photo contributor: Lawrence Heiskell, MD.)