The annual incidence of testicular torsion is 1/4000 in males under 25 years of age (Barada 1989). It has bimodal distribution – primarily a disease of neonates and adolescents, and is otherwise rare
The viability rates of a torted testicle declines significantly with time (Davenport 1996, Cokkinos 2011):
- 4-6 hours – 90-100% viable
- 12 hours – 20-50% viable
- 24 hour – 0%
Not only can fertility be reduced because the loss of a testicle, studies has demonstrated the development of an immunological process towards the contralateral testicle following the retention of an ischaemic testes, that can result in abnormal semen analysis, contralateral testicular atrophy and infertility.
Testicular torsion typically presents with an acute, sudden onset of scrotal pain, often associated with nausea (PPV 96%, sensitivity of 69%) and vomiting (PPV 98%, sensitivity 60%). However, the absence of nausea and/or vomiting should not exclude the diagnosis. It is reported that the duration of pain at the time of presentation is usually less than that of other non-surgical aetiologies of scrotal pain. Usually there is no precipitating event, however it commonly occurs during sleep and can even be a result of direct trauma.
Testis torsion in boys < 8 years can be painless or present with just abdominal pain; so always examine the testes in boys with abdominal pain.
Diagnosis using clinical examination alone can be challenging. It may be hindered by patient embarrassment, pain and equivocal or unreliable signs. Features on examination:
- Absence of cremasteric reflex
- The cremasteric reflex is illicited by stroking/pinching the medial aspect of the thigh, causing a contraction of the cremasteric muscle, and elevation of the ipsilateral testicle at least 0.5cm. Studies show the absence of a cremasteric reflex has a less than 90% sensitivity and specificity for diagnosing testicular torsion. However, it is important to note that over half of boys under 30 months have an absent cremasteric reflex bilaterally.
- Transverse lie
- Reported sensitivity 83%, specificity 94% and negative predictive value 95% (Cifti, 2004).
- High lie
- Studies have reported a ‘high lie’ of the testes in only 33-55% of testicular torsion cases (Mellick, 2011).
- Negative Prehn’s sign – historically used to differentiate torsion from epididymitis where scrotal elevation would provide relief of pain in epididymitis but not in testicular torsion.
Currently there is no validated, standardised set of clinical criteria for the diagnosis of testicular torsion.
Ultrasound should only be done in equivocal cases or where suspicion for torsion is low. An ultrasound should only be requested by a surgeon who has reviewed the patient.
If there is a high suspicion of testicular torsion, an ultrasound SHOULD NOT be performed and the patient should be taken to theatre as soon as possible for exploration.
The literature cites sensitivities of 78.6-100% and specificities of 76.9-100%, with a NPV of 100% (Liang 2013; Agrawal, 2014).
Urgent surgical exploration and de-torsion should occur within <6 hours of onset in order to salvage testicle. If testicular torsion is confirmed on exploration an orchiopexy will be performed, even if is not present, the surgeon may decide to perform a prophylactic orchiopexy to prevent occurrence in the future.
For children requiring surgery in the metropolitan area, an ED management algorithm has been designed by NSW Health that stipulates:
- Early recognition of children with surgical presentations and rapid escalation to most senior clinician
- A maximum of 2 hours as the interval between presentation and decision to admit/transfer
- Urgent local surgical intervention may be required for particular emergencies at ALL ages, where the risk due to time delay is considered paramount - testicular torsion is an example of this.
Manual detorsion is not an alternative to surgical exploration and orchiopexy, however, it may be a temporising measure until surgery is available. Apply the ‘open textbook’ technique, with external rotation of the affected testicle. For further information of this manoeuvre use this link.
- Infarction of testicle
- Testicular necrosis
- Cosmetic deformity
- Psychological Issues.
Further References and Resources
- Computer-Enhanced Visual Learning (CEVL) for Healthcare - Paediatric Acute Scrotal Pain e-learning module.
- Sheth, K.R. (2016) Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score, Journal of Urology, Vol. 195, No. 6, pp. 1870–1876.