Testicular Torsion

Testicular Torsion

Testicular torsion is a urological emergency caused by the twisting of the spermatic cord, which contains the testicular artery and veins. This twisting leads to vascular occlusion, causing ischaemia and, if not corrected promptly, infarction of the testis. The most common predisposing factor is the “bell-clapper” deformity, where the tunica vaginalis attaches high on the spermatic cord, allowing the testis to hang freely and rotate within the scrotum.

 

Clinical Diagnosis 

Diagnosis is primarily clinical and a high index of suspicion is crucial. Time is a major factor in testicular salvage, and surgical exploration should not be delayed by investigations.

  • Classic Presentation: Sudden onset of severe, unilateral testicular pain. This may be accompanied by abdominal pain, nausea, and vomiting.

  • Physical Examination:

    • High-riding testis: The affected testis appears higher than the contralateral one due to shortening of the spermatic cord.

    • Transverse lie: The testis may have a horizontal orientation.

    • Absent Cremasteric Reflex: This is a highly sensitive sign, though its absence is not pathognomonic. The cremasteric reflex is often preserved in torsion of the testicular appendage, a key differential diagnosis.

    • Negative Prehn’s sign: There is no pain relief upon elevation of the scrotum.

  • Investigations:

    • Ultrasound with Doppler flow imaging is an investigation to consider if there is a low suspicion for testicular torsion, but it should not delay surgical exploration if the clinical picture is highly suspicious.

    • The Testicular Workup for Ischaemia and Suspected Torsion (TWIST) score is a validated clinical scoring tool that can aid in risk stratification, allowing clinicians to make a more informed decision on the need for immediate surgery vs. observation and imaging.

 

Management

Testicular torsion is a time-critical surgical emergency.

  • Immediate Surgical Exploration: This is the gold standard of care. Delaying surgery for imaging can lead to testicular loss.

  • Time-critical intervention:

    • A significant reduction in testicular salvage rates occurs after 6 hours from the onset of symptoms.

    • UK guidelines emphasize that a surgical decision-maker should review the patient within 60 minutes of arrival at the emergency department, and surgery should ideally take place within 1 hour of the decision to operate.

  • Surgical Procedures:

    • Orchidopexy: If the testis is viable after detorsion, it is fixed to the scrotal wall to prevent recurrence. It is standard practice to fix the contralateral testis as well due to the bilateral nature of the “bell-clapper” deformity.

    • Orchidectomy: If the testis is not viable, it is surgically removed.

 

Recent Developments

Recent UK literature, particularly from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report “Twist and Shout” (2024) and the Getting It Right First Time (GIRFT) program, highlights key areas for improvement.

  • National Consensus Pathway: The GIRFT program, in collaboration with a multi-disciplinary expert group, has developed a national consensus pathway for the management of testicular torsion in children and young people. This aims to standardize care and reduce variability in practice.

  • Minimising Transfer Delays: A key focus is on reducing transfer times from district general hospitals (DGHs) to specialist centres. The new guidance states that, where possible, patients should be managed locally, with transfers reserved for exceptional circumstances (e.g., very young patients or those with complex comorbidities). This is a direct response to data showing that transfer delays lead to higher rates of orchidectomy.

  • Role of Ultrasound: Recent guidelines reinforce that ultrasound should not cause a delay in surgical exploration if there is high clinical suspicion of torsion. However, it can be useful in cases with low clinical suspicion, or for confirming an alternative diagnosis. The South Thames Paediatric Network (STPN) has specifically suggested that children under 5 years of age should be transferred to a tertiary paediatric surgery centre due to the higher incidence of negative explorations and low salvage rates in this age group, though a national consensus on a specific age for transfer is not yet fully established across all networks.

  • Public and Primary Care Awareness: There is a renewed emphasis on improving public and primary care awareness to reduce the time from symptom onset to presentation at a hospital. The NCEPOD report identified this as a significant factor contributing to delays.