Testicular Torsion Diagnosis: A Comprehensive Guide for Emergency Assessment

Introduction

Scrotal pain is a frequent complaint in emergency departments and primary care settings, accounting for approximately 0.5% of all emergency visits. Among scrotal emergencies, testicular torsion stands out as a critical urological condition. Prompt diagnosis and intervention are essential to preserve testicular viability and avert potential testicular loss. Ultrasound imaging is the preferred modality for evaluating scrotal pathology and diagnosing testicular torsion effectively. Rapid identification and management are crucial in these cases.

Etiology of Testicular Torsion

Testicular torsion arises from the twisting of the spermatic cord, which compromises the testicular blood supply. Intravaginal torsion, the more common type, typically occurs due to a congenital anomaly known as the bell clapper deformity. In this condition, the tunica vaginalis, instead of being firmly attached to the posterolateral aspect of the testicle, has a higher attachment. This allows the testicle and spermatic cord to rotate freely within the tunica vaginalis. The bell clapper deformity is often bilateral, present in about 40% of cases.

Extravaginal torsion, conversely, is more prevalent in neonates. It occurs because the tunica vaginalis is not yet fixed to the gubernaculum, leading to torsion of the entire complex, including the tunica vaginalis and spermatic cord, outside the tunica vaginalis. While classically neonatal, it’s important to recognize that intravaginal torsion can also occur in newborns. In adult populations, although rare, testicular torsion has been associated with underlying testicular malignancies.

Epidemiology of Testicular Torsion

Testicular torsion predominantly affects adolescents, coinciding with periods of rapid growth, but it can occur across all age groups, including prenatal and perinatal periods. It is the leading cause of testicular loss in males. The incidence is estimated to be approximately 1 in 4,000 males before 25 years of age. There is a bimodal age distribution, with peaks in infancy and adolescence.

Pathophysiology of Testicular Torsion

The pathophysiology of testicular torsion involves the rotation of the testicle on the spermatic cord, initially obstructing venous outflow. This venous congestion leads to testicular swelling and pain. As torsion progresses, arterial blood flow is impeded, resulting in testicular ischemia. If left untreated, this ischemia culminates in testicular necrosis. The degree of testicular rotation typically ranges from 90 to 180 degrees but can be more severe. The duration of torsion is a critical determinant of testicular viability. Testicular salvage rates are highest when intervention occurs within 6 hours of symptom onset, decreasing significantly after 12 hours, and becoming rare beyond 24 hours.

History and Physical Examination in Testicular Torsion Diagnosis

Patients with testicular torsion commonly present with a sudden onset of severe unilateral scrotal pain. The pain is typically constant and unrelated to position. Nausea and vomiting are frequent associated symptoms. Pain may also radiate to the lower abdomen or inguinal region, sometimes overshadowing the scrotal pain itself.

Physical examination may reveal a testicle that is abnormally positioned, often described as high-riding or in a transverse lie. The affected testicle may be swollen, tender, and erythematous. The cremasteric reflex, elicited by lightly stroking the inner thigh, is often absent on the affected side. However, the absence of this reflex is not entirely sensitive or specific for torsion, particularly in infants and young children. The Prehn sign, which suggests epididymitis if pain is relieved by elevating the testicle, is not a reliable indicator to rule out testicular torsion.

It’s important to differentiate testicular torsion from torsion of the testicular appendages, which is more common and benign. Appendage torsion may present with similar acute pain, but physical examination might reveal point tenderness at the superior pole of the testis or epididymis, a palpable nodule, or a characteristic “blue dot” sign due to the visibility of the cyanotic appendage through the scrotal skin. This blue dot is more likely in early presentation, and typically, appendage torsion resolves spontaneously without surgery.

Differential diagnoses for acute scrotal pain include epididymitis, orchitis, inguinal hernia, hydrocele, testicular tumors, and scrotal trauma.

Diagnostic Evaluation for Testicular Torsion

The TWIST (Testicular Workup for Ischemia and Suspected Torsion) scoring system is a clinical tool designed to risk-stratify patients for testicular torsion. It assigns points based on clinical findings:

• Testicular Swelling: 2 points
• Testicular Hardness: 2 points
• Nausea or Vomiting: 1 point
• Absent Cremasteric Reflex: 1 point
• High-Riding Testicle: 1 point

Higher TWIST scores correlate with a greater likelihood of testicular torsion. While the TWIST score can aid in risk assessment, imaging is crucial.

Ultrasound with Doppler is the primary imaging modality for Testicular Torsion Diagnosis. It boasts high sensitivity (around 93%) and specificity (nearly 100%) in experienced hands. The ultrasound examination should be performed promptly by trained sonographers. Point-of-care ultrasound (POCUS) can also be a valuable tool in the emergency setting.

The ultrasound technique involves a high-frequency linear transducer (5-10 MHz), copious gel, and appropriate patient positioning (supine, frog-legged with scrotal support). The unaffected testicle should be scanned first for comparison. Grayscale imaging assesses for hydroceles, testicular texture, and size. Normal testicular size is approximately 4 x 3 x 2.5 cm. Color Doppler and Power Doppler are essential to evaluate testicular blood flow. Comparison views of both testicles are critical to identify discrepancies in vascularity. In testicular torsion, reduced or absent blood flow in the affected testicle is a key finding. Power Doppler is more sensitive to low flow states but does not differentiate between arterial and venous flow. Spectral Doppler can further characterize arterial and venous waveforms, aiding in assessing the degree of vascular compromise.

Urinalysis is typically performed to evaluate for pyuria, which, if present, suggests infection, such as epididymitis or orchitis, but does not exclude testicular torsion.

Management of Testicular Torsion

While ultrasound is highly accurate, it is not infallible, especially in neonates where blood flow may be physiologically low. In cases of high clinical suspicion for testicular torsion, immediate urological consultation is paramount, irrespective of ultrasound findings. Time is critical; any delay can lead to irreversible testicular damage. The optimal window for surgical intervention and testicular salvage is within 6 hours of symptom onset.

Manual detorsion may be attempted as a temporizing measure if surgical intervention is not immediately available. The testicle should be rotated from medial to lateral (like opening a book) by 180 degrees and reassessed for pain relief. If pain worsens, rotation in the opposite direction should be considered. Ultrasound can be used to monitor for the return of blood flow after manual detorsion attempts.

Surgical exploration is the definitive treatment for testicular torsion. In neonates with suspected extravaginal torsion, bilateral scrotal exploration is typically performed. Orchiopexy, fixation of both testicles to the scrotum, is performed to prevent future torsion, even if only one testicle is torsed. If the testicle is non-viable at surgery, orchiectomy (testicular removal) may be necessary. Testicular prostheses can be inserted several months later for cosmetic reasons.

Differential Diagnosis of Testicular Torsion

• Epididymitis
• Orchitis
• Hydrocele
• Testicular Tumor
• Traumatic Hematoma

Prognosis of Testicular Torsion

Testicular salvage rates in testicular torsion have improved significantly over time, largely due to increased awareness and prompt intervention. However, outcomes are still less favorable in certain populations, including African Americans, younger patients, and those with delayed access to care. The best outcomes are observed when surgery is performed within 8 hours of symptom onset. Even after successful orchiopexy, there remains a risk of recurrence.

Complications of Testicular Torsion

• Testicular Loss (Orchiectomy)
• Testicular Atrophy
• Infection
• Infertility
• Cosmetic Deformity
• Endocrine and Exocrine Dysfunction

Enhancing Healthcare Team Outcomes in Testicular Torsion

Testicular torsion necessitates a coordinated interprofessional team approach for optimal patient outcomes. Emergency department triage nurses are the first point of contact and must be trained to recognize the signs and symptoms of testicular torsion. Prompt recognition and immediate notification of the emergency physician are crucial. The emergency physician should expedite radiological evaluation and consult urology urgently. Nurses play a vital role in preparing the patient for potential surgery, including NPO status and pre-operative blood work.

Effective communication among all team members—nurses, emergency physicians, radiologists, and urologists—is paramount to minimize delays in diagnosis and treatment. Educating patients and families about the condition, potential complications, and the importance of timely intervention is also essential. Pain management should be carefully considered, avoiding masking symptoms before urological assessment. A systematic and collaborative approach is key to maximizing testicular salvage rates and minimizing long-term complications of testicular torsion.

Review Questions

(Note: Review questions are accessed via the provided link in the original article and are not included here as per instructions.)

References

(References are identical to the original article and are listed below for completeness.)

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