Overview
Definition:
Testicular torsion is a surgical emergency caused by the twisting of the spermatic cord, leading to impaired blood supply to the testis and potential infarction
This occurs most commonly during adolescence but can affect any age group.
Epidemiology:
The incidence of testicular torsion is highest in males aged 12-18 years, with a bimodal peak in neonates and peripubertal boys
Approximately 1 in 3,500 to 1 in 40,000 males experience torsion annually
A history of previous episodes or trauma increases risk.
Clinical Significance:
Prompt diagnosis and surgical intervention are paramount to salvage the affected testis
Delayed treatment leads to testicular atrophy, infertility, and potential need for orchidectomy
Understanding diagnostic tools like the TWIST score and emergent management strategies like manual detorsion is crucial for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of severe, acute scrotal pain
Pain may radiate to the groin or lower abdomen
Nausea and vomiting are common
Absence of fever
Pain is typically unilateral
Previous intermittent episodes of pain relieved by lying down (intermittent torsion).
Signs:
Affected hemiscrotum is often swollen, erythematous, and tender
Testis may be elevated and lie horizontally (bell-clapper deformity is suggestive but not diagnostic)
Cremasteric reflex is often absent on the affected side
Scrotal edema and tenderness
Palpable, exquisitely tender spermatic cord.
Diagnostic Criteria:
Clinical suspicion based on acute scrotal pain and examination findings is primary
No definitive laboratory criteria exist
Imaging is supportive
The TWIST score aids in stratifying risk in suspected cases.
Diagnostic Approach
History Taking:
Detailed history of pain onset, character, and radiation
Associated symptoms like nausea, vomiting, fever
Previous episodes of scrotal pain
History of trauma or strenuous activity
Past medical and surgical history
Assess for urinary symptoms
Crucial for DNB/NEET SS case discussions.
Physical Examination:
Careful examination of external genitalia, palpating both testes for size, position, tenderness, and consistency
Assess for edema and erythema
Check for the presence or absence of the cremasteric reflex (elevation of testis when inner thigh is stroked)
Crucial to compare with the contralateral side
Avoid any manipulation that could exacerbate torsion if present.
Investigations:
Urinalysis: usually normal, may show hematuria if hemorrhagic infarction
Doppler Ultrasound: the gold standard for imaging
Demonstrates reduced or absent testicular blood flow
May show a normal flow in intermittent torsion or early stages
Orchidopexy may be visualized
Color Doppler is essential
Consider radionuclide scan if ultrasound is equivocal
Laboratory tests are not definitive for torsion itself.
Differential Diagnosis:
Epididymitis/Orchitis: often associated with fever, urinary symptoms, and a normal cremasteric reflex
Ultrasound may show enlarged epididymis and increased blood flow
Testicular trauma: history of injury
Inguinal hernia: reducible bulge in scrotum
Hydrocele/Varicocele: painless swelling, palpable difference in cord
Appendiceal torsion: less common, usually smaller and more superficial
Gartner duct cyst or spermatocele: palpable cystic masses.
Twists Score
Score Development:
The Testicular Injury - Scrotal Testis Score (TWIST) is a clinical decision rule designed to help clinicians differentiate testicular torsion from other causes of acute scrotal pain, particularly in pediatric patients
It aims to reduce unnecessary surgical exploration while ensuring timely intervention.
Components:
The TWIST score consists of 6 clinical variables: T: Testis High Position (1 point)
W: Testis to scrotum Wall Edema (1 point)
I: Nausea/Vomiting (1 point)
S: Absent or Decreased Spermatic Cord Doppler Signal (2 points)
T: High Testis Position + Firm Testis + Absent Cremasteric Reflex (all 3 = 2 points).
Scoring And Interpretation:
Score calculation: Grade 0-1: Low probability of torsion, consider imaging
Grade 2-3: Intermediate probability, strongly consider imaging and surgical exploration
Grade 4-6: High probability of torsion, proceed directly to surgical exploration
This is a critical tool for exam preparation focusing on evidence-based management.
Management
Initial Management:
Immediate assessment and pain management
IV fluids if dehydrated or vomiting
Prompt surgical consultation
Do NOT delay exploration for imaging if clinical suspicion is high
Manual detorsion can be attempted while awaiting surgery or if delays are anticipated.
Manual Detorsion:
This emergent procedure involves attempting to untwist the spermatic cord
It is typically performed when surgical exploration is delayed or not immediately available
The testis is usually twisted in a counterclockwise direction from the perspective of the patient looking down
Detorsion is performed in a clockwise direction
Assess for pain relief and improved testicular perfusion post-detorsion
if successful, it offers temporary relief until surgical fixation
This is a high-yield concept for board exams.
Surgical Management:
Surgical exploration is the definitive management for suspected testicular torsion
It involves incision and exploration of the scrotum, detorsion of the spermatic cord if twisted, and assessment of testicular viability
If viable, orchidopexy (surgical fixation) of the affected testis is performed to prevent recurrence
Contralateral orchidopexy is also recommended due to the high incidence of contralateral undescended testis or bell-clapper deformity
If non-viable, orchidectomy is performed.
Supportive Care:
Post-operative pain management with analgesics (e.g., paracetamol, NSAIDs)
Antibiotics if indicated (e.g., if infection suspected or post-orchidectomy)
Scrotal support and ice packs to reduce swelling
Monitoring for signs of infection or complications
Close follow-up is essential.
Complications
Early Complications:
Testicular infarction requiring orchidectomy
Scrotal hematoma
Wound infection
Testicular atrophy following successful detorsion and fixation
Acute epididymitis.
Late Complications:
Infertility due to impaired spermatogenesis or bilateral testicular damage
Testicular cancer risk is not definitively increased by torsion itself, but rather by the underlying predisposition for torsion (e.g., undescended testis)
Psychological impact and body image issues.
Prevention Strategies:
Surgical fixation of the testis (orchidopexy) is the primary prevention strategy for recurrent torsion
Education of adolescents and parents about the signs and symptoms of testicular torsion to seek prompt medical attention
Prompt management of any episodes suggestive of intermittent torsion.
Prognosis
Factors Affecting Prognosis:
The most critical factor is the duration from symptom onset to definitive surgical treatment
Testes salvaged within 4-6 hours have a significantly higher chance of survival and preserved function
Age of the patient, completeness of torsion, and extent of vascular compromise also play roles
Successful detorsion and orchidopexy offer a better prognosis.
Outcomes:
If treated within 6 hours, testicular salvage rates are high (>90%)
Beyond 12 hours, salvage rates drop dramatically (<10%)
Successful salvage leads to preservation of endocrine and fertility functions in most cases
Orchidectomy results in loss of testicular function and requires counseling regarding fertility and hormonal replacement if bilateral
Long-term fertility rates are often reduced even with salvage.
Follow Up:
Regular follow-up appointments with a pediatric urologist are essential to monitor testicular growth and function
This includes physical examinations and potentially hormonal assessments
Monitoring for psychosocial well-being related to body image and fertility concerns is also important
Review of contralateral testis is vital.
Key Points
Exam Focus:
Testicular torsion is a surgical emergency
do not delay exploration if high suspicion
TWIST score aids risk stratification
Manual detorsion is a temporizing measure
Orchidopexy of both testes is standard surgical management
Absent cremasteric reflex is a significant sign.
Clinical Pearls:
Always examine the external genitalia in boys with abdominal or flank pain
The "high-riding" testis and absent cremasteric reflex are classic findings
Remember to assess the contralateral testis for anatomical abnormalities and perform bilateral orchidopexy
Pain relief after manual detorsion suggests successful untwisting but does NOT negate the need for surgical fixation.
Common Mistakes:
Delaying surgical exploration for imaging when clinical suspicion is high
Mistaking torsion for epididymitis, especially in pre-pubertal boys where epididymitis is less common
Failure to perform bilateral orchidopexy
Over-reliance on ultrasound findings without considering clinical context
Inadequate history taking regarding prior episodes of pain.