Chapter 182: Manual Testicular Detorsion

INTRODUCTION

Testicular torsion was first described in the English literature in 1907.¹ Testicular torsion occurs when the testicle twists around its axis and causes vascular compromise of the testicle (Figure 182-1). Testicular torsion is a clinically diagnosed and time-sensitive emergency. The goal of the Emergency Physician is to suspect the diagnosis, make the diagnosis, and facilitate rapid operative detorsion by a Urologist. Manual detorsion can be attempted while awaiting surgical intervention.

The incidence of testicular torsion is approximately 3.5 to 4.5 in 100,000 males < 25 years of age.^2,3 It primarily affects young persons with a bimodal age distribution. The most common occurrence is in the neonatal period with the second peak at approximately age 13.⁴ Most cases of testicular torsion occur in patients < 21 years of age.⁵ Rare cases of testicular torsion in men > 59 years of age have been reported.^6-9 The age range at risk for torsion is broader than commonly thought.

Testicular torsion cannot be ruled out by history and physical examination.^10,11 There are commonly associated history and physical examination features. Testicular torsion classically presents with acute onset of excruciating pain in the unilateral testicle or scrotum. Cases of bilateral testicular torsion can occur.¹² Testicular torsion may be associated with a recent history of genital trauma including self-mutilation in up to 8% of cases.^13,14 Associated symptoms may include a low-grade fever, nausea, and vomiting.^15,16 A history of a prior orchiopexy (i.e., surgical fastening of the testicle) does not exclude a testicular torsion.¹⁷ Patients may present immediately upon the onset of pain or days later. Delayed presentation can sometimes occur in patients who have a history of chronic intermittent torsion.

Patients typically have testicular pain to palpation and a painful, edematous scrotum. The testicle can present with a high-riding horizontal lie with anterior rotation of the epididymis (Figure 182-1).^16,18,19 This testicle positioning is not universal.¹⁰ A cremasteric reflex was typically absent in one trial.²⁰ The cremasteric reflex remains present in testicular torsion in 8% to 40% of cases.^19-24 Prehn’s sign (i.e., relief of pain with elevation of the scrotum) is classically present in epididymitis and absent in testicular torsion. It too is an imperfect discriminator.^25-28 Color Doppler ultrasound (US) studies can be misleading because scrotal blood flow can be misinterpreted as testicular blood flow.^11,29 A lack of flow assumes testicular torsion is present with a sensitivity of 45% to 60%.³⁰

Color Doppler US is the initial test of choice because of its greater availability, lower cost, lack of adverse ...