You have a new patient!
You are on a busy overnight shift at the local emergency department when you pick up the chart of an 18-year-old male with abdominal pain and vomiting. You walk into the room and see a young male sitting in bed and appearing in moderate distress. His mother accompanies him. He states that he woke up from sleep with severe lower abdominal pain. He reports associated nausea and two episodes of non-bloody, non-bilious vomiting.
Vital signs are as follows: Blood Pressure 140/65 mmHg, Heart Rate 110 bpm, Respiratory Rate 20 bpm, Oxygen Saturation 100% in room air, and Temperature 98.7 (37.0 Celcius) oral.
The patient appears guarded as if he is holding back information.
You politely ask his mother to step out of the room so that you can examine the patient. With his mother gone, he states the pain is actually in his testicle. It woke him up from sleep and caused him to vomit. The pain is described as severe and began acutely two hours ago.
What do you need to know?
Importance
Testicular torsion is a urological emergency necessitating emergent intervention. Time is testicle! This can-not-miss diagnosis needs to be made quickly, as salvage rates are directly related to detorsion time. Testicular ischemia can develop as early as 4-8 hours after the onset of testicular torsion [1]. Early recognition of testicular torsion has been associated with an increase in the rates of testicular salvage and the prevention of complications, such as testicular infarction and infertility [2].
Epidemiology
Testicular torsion can occur at any age but occurs more often after birth or between 12-18. The peak incidence of testicular torsion is at age 13-14 years. The incidence of torsion in males below the age of 25 is approximately 1 in 4000 [2].
Pathophysiology
Testicular torsion occurs when the testicle rotates around its spermatic cord, leading to impaired testicular blood supply, tissue ischemia, and pain [3]. Torsion results from abnormal fixation of the testis to the tunica vaginalis, an anatomical layer outside the testis that forms a sac. Torsion may occur spontaneously, after episodes of minor trauma, during periods of testicular growth (e.g., puberty), or during sleep when unilateral cremasteric muscle contraction results in twisting of the testis. Inadequate fixation of the tunica vaginalis to the posterior scrotal wall, known as the bell-clapper deformity, also places the testis at increased risk of torsion [4].
Initial Assessment and Stabilization (ABCDE approach)
Obtaining a detailed history is critical to developing your differential diagnoses. When concerned about testicular torsion, ask about the pain’s location and time of onset. Associated symptoms are also important, as nausea or emesis often accompanies this diagnosis. Ask about fevers, trauma, rashes, dysuria, hematuria, diarrhea, or blood stools, as these additional symptoms may make other diagnoses more likely.
Key features in the history that may heighten the index of suspicion include young patient age, sudden onset of symptoms, and severe unilateral testicular pain lasting less than 24 hours. However, testicular pain lasting over 24 hours does not necessarily rule out the presence of a testicular torsion [1].
Risk factors to ask about are the presence of an undescended testicle or a bell-clapper deformity. Testicular salvage rates are directly correlated to detorsion time, so gathering a focused history is important. The testicular salvage rate is 90-100% with symptoms <6 hours and 0-10% when torsion is >24 hours [1].
Medical History
Key features in the medical history of meningitis include the onset and duration of symptoms, recent travel or exposure to infectious agents, immunization status, underlying medical conditions, and medication use. It is important to obtain a detailed history of present illness, including the timing and progression of symptoms such as fever, headache, neck stiffness, altered mental status, and rash. Patients may also report symptoms such as nausea, vomiting, photophobia, and seizures. Recent travel or exposure to individuals with known or suspected meningitis can help identify potential infectious agents. Immunization status, particularly regarding vaccines against meningococcal and pneumococcal infections, is also important to determine. Patients with chronic medical conditions or who are taking immunosuppressive medications may be at increased risk for certain pathogens or complications.
Physical Examination
A thorough abdominal and genitourinary exam needs to be completed on a patient with suspected testicular torsion. Have a chaperone in the examination room, and consider asking the parent(s) to leave the room in the adolescent-age child. The exam focuses on the scrotum and testicles, but evaluating for inguinal hernias ab, abdominal tenderness, or distension is important. A skin and penile exam should also be performed, taking time to evaluate for skin changes or any evidence of infection.
Exam findings in testicular torsion may include scrotal swelling or erythema, testicular tenderness, an elevated or “high riding” testicle (Brunzel sign), horizontal lie of the testicle, and dimpling of the scrotal skin (Ger’s sign). Testicular pain is generally not relieved with elevation of the affected testicle (Prehn’s sign). Evaluating an absent cremasteric reflex on the affected testicle is also highly sensitive for testicular torsion [2].
Pain from testicular torsion can be constant or intermittent since a torsion/detorsion phenomenon can occur. In intermittent testicular torsion, it is important to maintain a high clinical suspicion based on symptoms, risk factors, and demographics [2].
When to Ask for Senior Help
If you are not confident about your exam findings or approach to the patient, you should ask for assistance. If suspicion of testicular torsion is high, inform your senior resident or supervising doctor to confirm that your patient assessment and plan are appropriate.
Not-to-Miss Diagnoses
Testicular torsion is a time-sensitive diagnosis to consider for any male patient with testicular pain, unexplained abdominal or flank pain, low back pain, or vomiting. There are other diagnoses that have overlapping signs and symptoms with testicular torsion. See below for these alternative diagnoses to consider.
Other diagnoses include:
- Scrotal wall cellulitis
- Scrotal hematoma
- Scrotal abscess
- Epididymitis
- Orchitis
- Fournier gangrene
- Hematocele, hydrocele, spermatocele, pyocele, or varicocele
- Incarcerated or strangulated inguinal hernia
- Lymphadenitis
- Tinea cruris
- Testicular rupture
- Testicular tumor or malignancy
- Torsion of testicular appendage
- Appendicitis
- Bowel obstruction
- Sexually transmitted infection
- Urinary tract infection or pyelonephritis
Acing Diagnostic Testing
The diagnosis of testicular torsion is based on the patient’s symptoms and physical exam. Investigation can be ordered if the diagnosis is unclear or alternative diagnoses are strongly considered. However, a urology specialist should be consulted based on clinical suspicion of torsion. Consultation for definitive management should not be delayed for investigations.
The TWIST score is a proposed score for assessing testicular torsion in children [5].
Patients receive:
- 2 points for testicular swelling
- 2 points for a hard testicle
- 1 point for an absent cremasteric reflex
- 1 point for nausea or vomiting
- 1 point for a high-riding testicle
A TWIST score greater than 5 was found to have a positive predictive value of 100% (suggesting a stat urological consult). A score less than 2 was found to have a negative predictive value of 100% (suggesting clinical clearance). Scores between 2-5 require ultrasound for further assessment [5].
Investigations to consider based on the patient’s history and physical exam are below:
- Testicular ultrasound. Consider ultrasound in equivocal cases (TWIST Score 2-5) [5].
- A positive exam will show unilateral absence of blood flow, an enlarged testicle, and asymmetric testicular echotexture on sonogram [6].
- Pre-operative labs, such as blood count, chemistry, and coagulation studies
- Urinalysis
- Testing for sexually transmitted infections
- CT imaging of the abdomen and pelvis to evaluate for alternative diagnoses (e.g., appendicitis)
Scrotal/Testicular Ultrasound
Ultrasound is the preferred method. In patients with testicular torsion, the ultrasound shows a hypoechoic and enlarged testis. Reduced blood flow and parenchymal heterogeneity are other signs of testicular torsion.
Management
Empiric and Symptomatic Treatment
Patients with concern for testicular torsion may need analgesia and antiemetic medications for symptom control. Some recommendations are below.
Analgesics:
- Acetaminophen (peds), 15mg/kg PO, q4-6h, Max 4000mg/day, caution with allergies or if they have already taken
- Ibuprofen (peds), 10mg/kg PO, q6h, Max 2000mg/day, caution with allergies or if they have already taken
- Morphine, 0.1mg/kg IV, initial dose than 0.05mg/kg q30min until desired analgesia, caution with allergies or depressed mental status
- Fentanyl, 1mcg/kg IV, initial dose than 0.5mg/kg q15min until desired analgesia, caution with allergies or depressed mental status
Antiemetics:
- Ondansetron, 0.1mg/kg IV; give 2mg in patients <20kg and 4mg in patients >20 kg
Procedures
If there is a high index of suspicion for testicular torsion, a urologic specialist should be promptly consulted for definitive surgical intervention. If urology is unavailable, or a prolonged time to surgical treatment is anticipated, manual de-torsion can be attempted in the emergency department [1].
Manual de-torsion [1]
- Temporizing measure if a urologist is not immediately available
- De-torsion in the emergency department does not replace formal intraoperative de-torsion and surgical fixation of the testis (orchiopexy)
- First, provide intravenous analgesia or administer a spermatic cord anesthetic block.
- Second, grasp the affected testicle and rotate it from medially to laterally (“open the book”). Rotate the testicle at least 360 degrees or until pain is improved.
- Consider repeating rotation in the medial to lateral direction 2-3 more times or until pain is decreased.
- If pain worsens after rotation or if rotation is not successful, attempt to rotate the testicle in the opposite direction.
When To Admit This Patient
Patients with high clinical concern for testicular torsion should be evaluated promptly by a urologist. If no urologist or surgical specialist is immediately available, these patients should be transferred to another facility for urologic evaluation. Testicular torsion patients should be admitted for surgical detorsion and orchiopexy by urology [1].
If the clinical diagnosis of torsion is unclear (e.g., TWIST score 2-5), further testing with testicular ultrasonography can aid in disposition planning [5].
Revisiting Your Patient
You carefully perform a genitourinary exam with the patient’s mother outside of the examination room. You note an elevated, firm, swollen, erythematous left testicle with an absent cremasteric reflex on the left side.
You immediately call your senior for help. You calculate a TWIST score of 6, raising testicular torsion high on your differential diagnoses list, and urology is consulted for suspected testicular torsion. While you await urology, you give the patient 0.1mg/kg IV morphine and attempt manual detorsion in the emergency department. Pain does improve slightly by the time urology arrives. Despite the high TWIST score, they perform a quick bedside ultrasound that shows diminished flow to the left testicle. They informed you that they would take the patient to the operating room for detorsion and orchiopexy. The patient is admitted to the urology service and leaves the emergency department for the operating room.
Authors
Vlad Panaitescu
Elizabeth Zorovich
Vincent Gonzalez
Listen to the chapter
References
- Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835–840.
- Laher A, Ragavan S, Mehta P, Adam A. Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies. Open Access Emerg Med. 2020;12:237-246. Published 2020 Oct 12. doi:10.2147/OAEM.S236767
- Fujita N, Tambo M, Okegawa T, Higashihara E, Nutahara K. Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Res Reports Urol. 2017;9:169–174. doi: 10.2147/RRU.S140361
- Davis JE. Male Genital Problems. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw Hill; 2016.
- Barbosa JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.
- University of Arkansas for Medical Sciences, Department of Radiology. Testicular Torsion. https://medicine.uams.edu/radiology/kb/testicular-torsion/ . Published on 8 October 2022. Accessed on 12 November 2024.
Reviewed and Edited By
Joseph Ciano, DO, MPH, MS
Dr. Ciano is a board-certified attending emergency medicine physician from New York, USA. He works in the Department of Emergency Medicine and Global Health at the Hospital of the University of Pennsylvania. Dr. Ciano’s global work focuses on capacity building and medical education and training in low-middle income countries. He is thrilled to collaborate with the iEM Education Project in creating free educational content for medical trainees and physicians.
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
