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.
Torsion of the right testicle. The testicle lies horizontally and in a higher position than the normal testicle.
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 ...