Chapter 151. Manual Testicular Detorsion

First described in the English literature by Rigby and Howard in 1907, testicular torsion occurs when the testicle turns around its axis, forcing its blood supply to twist, thereby causing vascular compromise of the testicle (Figure 151-1).1 Testicular torsion is a time-sensitive emergency that demands the Emergency Physician to act swiftly to preserve the testicle. Testicular torsion is a clinical diagnosis and the primary goal is surgical detorsion in the operating room. If testicular torsion is strongly suspected clinically, consult a Urologist immediately for a bedside evaluation. Manual detorsion can be attempted while awaiting more definitive surgical intervention.

The incidence of testicular torsion is believed to be approximately 1 in 4000 in males less than 25 years of age.2 It is primarily a condition that affects the young with a bimodal distribution in the neonatal period and the early teens.3 Most cases occur in patients less than 21 years of age.4 Age should not be considered when making the diagnosis, however, as torsion may occur in the antenate, neonate, adult, or geriatric patient.5–7

Testicular torsion typically presents with acute or insidious onset of excruciating, usually unilateral testicular and/or scrotal pain. There is a slight predilection for the left testicle.2 Cases of bilateral torsion can also occur.8 Torsion may be associated with a history of a recent episode of genital trauma.9 The patient is often awaken from sleep by the pain. Associated symptoms may include nausea, vomiting, and a low-grade fever.10 A history of a prior orchiopexy (surgical fastening of the testicle) does not exclude the possibility of torsion.11

Physical examination of these patients typically reveals testicular pain to palpation and a painful, edematous scrotum. The testicle may be high-riding with a horizontal lie and anterior rotation of the epididymis.12 A cremasteric reflex is typically absent but can be present in some cases. Lack of a cremasteric reflex has only a 88.2% sensitivity for torsion.13–15 Prehn's sign, or the relief of pain with elevation of the scrotum, is classically present in epididymitis and absent in torsion. Unfortunately, Prehn's sign is an imperfect discriminator.16–18 Bedside Doppler ultrasound stethoscope studies can be misleading, even if flow is heard.19 Scrotal blood flow can be erroneously interpreted as testicular blood flow.19 If flow is not heard, however, one can assume torsion is present.

Color Doppler ultrasonography has largely replaced testicular radionuclide scintigraphy for the confirmation of torsion because of its greater availability, lower cost, and lack of adverse effects. However, two points must be emphasized. In a patient where torsion is strongly suspected, emergent bedside consultation with a Urologist should not be unduly delayed for the performance of or the results of a radiological study. This point becomes even more critical the longer the symptoms have been present. Color Doppler ultrasonography has a reported sensitivity for torsion of only 85.7% to 90%.20–23 If torsion is suspected and no other competing diagnosis can be definitively confirmed by color Doppler ultrasonography, the patient should still be emergently evaluated by a Urologist.

The differential diagnosis of the acutely swollen or painful scrotum also includes torsion of the testicular appendage, epididymitis, orchitis, hernia, varicocele, tumor, trauma, idiopathic scrotal edema, fat necrosis, viral inflammation, and Henoch–Schönlein purpura. As testicular torsion is the diagnosis requiring the most urgent action, it should be first on the differential diagnosis list. Testicular torsion may result in irreversible damage to the involved testis. It may also affect the contralateral testicle. Recent studies have examined the possible immunologic mechanism for this global effect on fertility but the exact pathophysiology has not been established.24,25

The testicle is covered by the tunica albuginea, followed by the visceral layer of the tunica vaginalis. The parietal layer of the tunical vaginalis partially encloses both the testicle and the epididymis. The testicular (spermatic) artery acts as the primary blood supply to the testicle and traverses the spermatic cord. Venous drainage is supplied by the pampiniform plexus within the spermatic cord. The above structures, as well as the vas deferens, are enveloped by the cremaster muscle and fascia.

Testicular torsion may be classified as extravaginal or intravaginal.26 Extravaginal torsion occurs primarily in neonates. The testis, epididymis, and tunica vaginalis twist together on their vertical axis because the gubernaculum has not yet become attached to the scrotal wall. It is thought to be caused by the free rotation of the testicle around the spermatic cord at a level above the tunica vaginalis.15,27 Intravaginal torsion occurs in peri- or postpubertal males and has been associated with the so-called bell-clapper deformity. In the normal scrotum, the tunica vaginalis only partially covers the epididymis and does not cover the spermatic cord. In the bell-clapper deformity, the tunica vaginalis encases the entire testicle, epididymis, and base of the spermatic cord. This allows the contents to twist and move within the tunica vaginalis as a bell-clapper does within a bell.26 Both intravaginal and extravaginal torsion usually occur in a medial or inward fashion.

Testicular torsion results in the obstruction of the blood supply to the testis. The venous obstruction leads to edema. This is followed by arterial obstruction that leads to testicular ischemia. Because the degree of torsion or vascular compromise cannot be quantified by current methods, the time for torsion to result in irreversible testicular damage cannot be determined.26 A complete vascular occlusion will cause a testicle to develop permanent and irreversible damage earlier than a testicle with partial vascular occlusion. The literature is variable and cites a range of 6 to 24 hours of vascular occlusion required to cause irreversible ischemic damage to a testicle. Most authors agree that the best outcomes are obtained with detorsion within 6 hours of symptom onset.26 Incomplete torsions exist and some blood flow to the testicle may be preserved. Therefore, a testicle should not be assumed to be nonviable based upon the time of suspected onset alone.

The definitive therapy for a torsed testicle is surgery. There is agreement that, at the time of surgery, a necrotic testicle should be removed and a pink, healthy appearing testicle should be left in place. The question remains of what to do with those testicles whose viability is not clear at the time of surgery. Current recommendations are to remove an obviously necrotic testicle or a testicle that stays cyanotic after detorsion; but leave in place any testicle which appears viable.28,29

Research has addressed the issue of immunology and future fertility post-torsion. The blood-testicle barrier has been well established. The theory exists that ischemic damage to the torsed testicle breaks down the blood-testicle barrier allowing the body to produce autoantibodies that attack the contralateral testicle.25 Another theory has proposed that abnormal or subfertile testicles are more likely to torse and that these differences in fertility may have predated the torsion.30,31 These subfertile changes may resolve within several months after orchiectomy of the torsed testicle.24 Studies in sperm-producing rodents have found evidence of immunologic damage to the contralateral testicle after torsion, especially if the torsed testicle is allowed to remain torsed for more than 24 hours.24,25 These studies and others seem to support the theory of immunologic damage after ischemia.

The Emergency Physician should attempt manual reduction of a torsed testicle while awaiting the arrival of the Urologist.32 An attempt should be made to manually reduce all suspected testicular torsions while awaiting the arrival of the Urologist.32 If reduced within 6 to 8 hours of the start of symptoms, the survival rate of the testicle after manual detorsion is near 100%.32 After 8 hours, the risk of testicular atrophy increases but the testis may still be salvageable; especially if the vascular obstruction is incomplete. Successful manual detorsion after longer periods of time becomes difficult due to edema formation. However, due to the lack of significant complications, manual detorsion should be attempted regardless of the length of symptoms as long as it does not delay definitive surgical management.

There are no absolute contraindications to attempt to manually reduce a testicle that is torsed. There are, however, some situations in which it might not be warranted. If the testis has become fixed to the scrotal wall, it may be necrotic and detorsion outside of the Operating Room is not possible.32 If the Operating Room and Surgeon are available, an attempt at manual detorsion might delay definitive repair. If the degree of swelling and/or pain preclude the examiner from applying firm pressure on the testicle, detorsion might not be possible. If the clinical picture suggests another cause for the patient's symptoms and the suspicion for a testicular torsion is very low, a radiologic study (i.e., testicular scan or Doppler ultrasound) might be warranted prior to an attempt at detorsion. If the testicle has been torsed for more than 24 hours, orchiectomy without detorsion might help to preserve fertility in the contralateral testicle.25 However, this has not been sufficiently confirmed and is not currently recommended.

No equipment is required to manually detorse a testicle. However, as the testicle is tender and the procedure is bound to be painful, consider the judicious administration of parenteral analgesia, sedation, or procedural sedation (Chapter 129). The use of a Doppler stethoscope or color Doppler ultrasound to assist with the diagnosis and determination of a successful detorsion is helpful but not required.

Explain the procedure to the patient and/or their representative. Explain that the procedure will be quick but painful. Explain that giving medicine to relieve the pain may interfere with the determination of success. Inform the patient that there are no risks to attempting to manually reduce the torsed testicle. Potential complications include continued pain, increased pain, and the inability to detorse the testicle. No matter what result is obtained with manual detorsion, an operation will be necessary prior to discharge to prevent future episodes of torsion.10 If manual detorsion is unsuccessful, emergent operative intervention may be required. Therefore, the patient should be kept non per os (NPO).

The use of anesthesia is not absolutely contraindicated. It may be required depending on the patient's age, ability to cooperate, and the examiner's preference. The use of a spermatic cord block should be avoided as it interferes with the patient's ability to assess pain and the determination of a successful detorsion.30 The injection of local anesthetic solution into the spermatic cord may further compromise testicular blood flow.31 Options for pain relief, when required, include procedural sedation (Chapter 129), intravenous analgesics, and/or intravenous sedatives.

The direction of most torsions has been described as inward or medial, but they can also be outward or lateral.10 This rotational predilection explains why the initial detorsion attempt should be in an outward or lateral direction (Figure 151-2). This has also been described as “detorse as you would open a book” or “supinate the hand as the testicle is rotated.”30 Another way to think of it is if you are looking at the patient from the foot of the bed. Rotate the patient's right testicle counter clockwise and the patient's left testicle clockwise (Figure 151-2).

Place the patient semirecumbent or supine. Stand next to the patient. Place the dominant hand on the patient's torsed testicle. Grasp the spermatic cord with the other hand to stabilize it from moving. Grasp the testicle gently but firmly. Rotate the testicle within the scrotum 180° outward (Figure 151-2). There should be no resistance to the rotation. While some authors have maintained the need to rotate the torsed testicle in two planes33 (caudal to cranial and medial to lateral), others have reported success with single plane rotation.26

The average degree of torsion has been cited as 720°. It can range from 180° to 1080°.10 Continue to detorse the testicle until the patient experiences pain relief and the normal scrotal anatomy is restored.26 If at any point in the procedure the patient experiences an increase in pain or there is resistance to rotating the testicle, stop and attempt to detorse the testicle in the opposite direction.32 Occasionally, a testicle may be torsed outward or laterally.

Successful detorsion is marked by both the sudden relief of pain and the restoration of the normal scrotal anatomy. The normal anatomy is indicated by a lengthening of the spermatic cord and a vertical lie of the testicle.33 If available, a Doppler stethoscope or color Doppler ultrasound may be used to monitor the effects of the detorsion. The resolution of edema will depend on the degree and duration of ischemia, but will not be as immediate as the pain relief. If the patient has relief of pain but the testicle is still high riding or horizontal, continue to detorse the testicle in the same direction until there is complete pain relief and a return of the normal scrotal anatomy.

All patients with a diagnosis of testicular torsion should be admitted to the hospital with an emergent Urological consultation. This is true despite a successful manual detorsion. The timing of the operative intervention will be changed from emergent to urgent if the testicle is detorsed in the Emergency Department.32,34,35 Urgent surgery is still required because, even with pain relief, the torsion may not have been completely reduced. One study found evidence of continued torsion with venous congestion even after successful manual detorsion. Following testicular torsion, the patient must undergo bilateral orchiopexy. The bell-clapper deformity that is implicated in many testicular torsions is almost always bilateral.15 Therefore, the contralateral testicle is at increased risk for torsion.

There are few complications to manual detorsion and none that should deter the Emergency Physician from an attempt at detorsion should it be indicated. The procedure is painful and detorsion in the wrong direction will initially increase the patient's discomfort. There is also the possibility that, despite proper technique, the Emergency Physician will be unable to detorse the testicle and emergent surgery will be required. If it turns out that testicular torsion is not the correct diagnosis, the patient will have endured an uncomfortable procedure without gain. While detorsion in the wrong direction may temporarily increase the degree of vascular compromise, it should cause no increase in ischemia if detorsed in the opposite direction. Complications may also arise from a delay in notification of the Urologist.30

A more serious potential complication stems from the false sense of security obtained when the patient has pain relief. Manual detorsion may only partially restore blood flow and rapid surgical intervention may still be required. Delaying the trip to the Operating Room due to lack of pain may cause “castration by procrastination.”30

Due to the risk of impaired fertility after torsion, all efforts must be undertaken to preserve the contralateral testicle and future fertility. Animal studies suggest that detorsion of an ischemic testicle can cause neurohormonal-mediated damage to the contralateral testicle.36,37 However, these theories remain controversial and should not be used to justify not attempting a manual detorsion.15,38

Emergency Physicians must be aware of the possibility and urgency of a testicular torsion. They should be prepared to rapidly attempt manual detorsion since “time is testicle.” Early notification of the Urologist is essential as the ischemia time and testicular salvage are inversely proportional. Manual detorsion should be attempted on all patients as it may successfully relieve or reduce the ischemia, increasing testicular survival and future fertility. All patients with testicular torsion should receive definitive therapy and repair in the operating room to prevent future episodes of torsion.