1204 Testicular Torsion

performed. Attempts at manual detorsion should

BASIC INFORMATION DIAGNOSIS not delay surgical consultation.
DEFINITION Diagnosis is made mainly by clinical suspicion PROGNOSIS
Testicular torsion is a twisting of the spermatic (Table ET1-4). Color Doppler ultrasound evalu- • The degree of ischemia depends on the dura-
cord leading to cessation of testicular blood ation or a nuclear testicular scan (Fig. ET1-10) tion of torsion and the degree of rotation of
flow, ischemia, and infarction if left untreated. may help with the diagnosis. Ultrasonography the spermatic cord.
will show absent or decreased blood flow; • There is an 80% testicular salvage rate if
SYNONYMS scintigraphy reveals decreased perfusion on detorsion occurs within 12 hr of onset.
Spermatic cord torsion symptomatic side. • After 24 hr, irreversible testicular infarction is
expected.
ICD-9CM CODES DIFFERENTIAL DIAGNOSIS • Because the contralateral testes can be
608.2  Testicular torsion See Fig. T1-11. affected (immunologic process), when treat-
ICD-10CM CODES • Torsion of the testicular appendages (appen- ment is delayed and return of blood flow does
N44.03  Torsion of testis, unspecified dix testis) not occur after detorsion, some recommend
• Testicular tumor orchiectomy of the infarcted testicle.
• Epididymitis
EPIDEMIOLOGY & • Incarcerated inguinoscrotal hernia REFERRAL
DEMOGRAPHICS • Orchitis To urologist
INCIDENCE: Affects one in 4000 males aged • Spermatocele
<25 yr • Hydrocele, varicocele
PREDOMINANT AGE: Two thirds of all cases PEARLS &
occur between the ages of 12 and 18 yr, but WORKUP CONSIDERATIONS
may occur at any age, including antenatally. The diagnosis is usually based on history and
physical examination. • Manual detorsion by external rotation of the
PHYSICAL FINDINGS & CLINICAL testis toward the thigh can be attempted for
PRESENTATION IMAGING STUDIES adolescent intravaginal torsion if an operat-
• Typical sequence is sudden onset of hemis- • Radionuclide scrotal scanning (technetium- ing facility is not readily available.
crotal pain, then swelling, nausea, and vomit- 99m): cold testicle • Extravaginal torsion is diagnosed in the new-
ing without fever or urinary symptoms. • Doppler ultrasonic stethoscope (Doppler born. Intravaginal torsion can occur at any
• Physical examination may reveal a tender flowmetry) age but is usually diagnosed in males ages
firm testis, high-riding testis, horizontal lie 12 to 18 yr.
of testis, absent cremasteric reflex, and no
pain with elevation of testis. Absence of the TREATMENT
cremasteric reflex (stroking or pinching the SUGGESTED READINGS
Surgical derotation of the spermatic cord fol-
medial thigh normally causes contraction of Available at www.expertconsult.com
lowed by bilateral testicular fixation with non-
the cremaster muscle and elevation of the
absorbable sutures. If the affected testis is RELATED CONTENT
testis) is the most sensitive physical finding.
nonviable, orchiectomy of the affected testis
• Painless testicular swelling occurs in 10%. Testicular Torsion (Patient Information)
and orchiopexy of the contralateral side are
• One out of three patients reports previous AUTHOR: FRED F. FERRI, M.D.
episodes of spontaneously remitting scrotal
pain.
• In the neonate, testicular torsion should be
Penis
presumed in patients with a painless, discol- Epididymis
Twisted cord
ored hemiscrotal swelling. swollen and
• In rare cases, torsion may involve an unde- tender
Affected side
scended testicle. In such situations an empty Testis
hemiscrotum is palpated together with a
tender lump in the inguinal area. Testicular Torsion
Indurated
Epididymitis
cord

ETIOLOGY
• There are two types of testicular torsion:
extravaginal, caused by nonadherence of
the tunica vaginalis to the dartos layer, and
intravaginal, caused by malrotation of the
spermatic cord with the tunica vaginalis. Tumor
Intravaginal torsion accounts for 90% of mass
cases. Testicular Tumor
• Torsion usually occurs in the absence of any
precipitating events. Trauma accounts for FIGURE T1-11  Physical findings in acute scrotum.  Upper left, Testicular torsion. Upper right,
<10% of cases. Epididymitis. Lower, Testicular tumor. Scrotal examination, which begins with palpation of the scrotal contents,
should be performed in the following order: (1) testes, (2) epididymides, (3) spermatic cord structures, and (4)
inguinal ring. (From Nseyo U, Weinman E, Lamm DL: Urology for primary care physicians, Philadelphia, 1999,
WB Saunders.)
Testicular Torsion 1204.e1

SUGGESTED READING
Ringdahl E, Teague L: Testicular torsion, Am Fam Physician 74:1739, 2006.

TABLE ET1-4  Differentiation of Testicular Torsion, Epididymitis, and Appendage Torsion

Testicular Torsion Epididymitis* Appendage Torsion
Historical Features
Age Peak incidence in neonatal and adolescent Primarily adolescents and adults but Typically prepubertal boys
groups but may occur at any age may occur at any age
Risk factors Undescended testicle (neonate), rapid Sexual activity or promiscuity, GU anom- Presence of appendages
increase in testicular size (adolescent), alies, GU instrumentation
failure of previous orchiopexy
Pain onset Sudden Gradual Gradual or sudden
Previous episodes of similar pain Possible (spontaneous detorsion) Unlikely Occasional
History of trauma Possible Possible Possible
Nausea, vomiting More likely Less likely Less likely
Dysuria Less likely More likely Less likely
Physical Findings
Fever Less likely More likely, particularly with advanced Less likely
disease (epididymoorchitis)
Location of swelling and Testicle, progressing to diffuse hemiscro- Epididymis, progressing to diffuse Localized to head of affected tes-
tenderness tal involvement hemiscrotal involvement ticle or epididymis
Cremasteric reflex Testicular torsion less likely if present May be present or absent May be present or absent
Testicle position High-riding testicle, transverse alignment Normal position, vertical alignment Normal position, vertical alignment
Pyuria Less likely More likely Less likely

GU, Genitourinary.
*Including epididymoorchitis.
From Adams JG et al: Emergency medicine, clinical essentials, ed 2, Philadelphia, 2013, Elsevier.

FIGURE ET1-10  Testicular torsion.  Evaluation of blood flow to the testicle has been done by giving an intravenous bolus of radioactive material. The right and left
iliac vessels are clearly identified, and sequential images are obtained every 3 sec. Here, increased flow is seen to the rim of the left testicle (arrows), and there is no
blood flow centrally. This is the appearance of a testicular torsion in which the torsion has been present for more than approximately 24 hr. (From Mettler FA [ed]: Primary
care radiology, Philadelphia, 2000, Saunders.)