Testicular torsion

Occurs when the spermatic cord twists so cuts off the blood supply to the testicle. It is an emergency requiring urgent assessment, diagnosis and surgical exploration to salvage the testis.

Testicular torsion is a clinical diagnosis.

History

• Symptoms usually include sudden onset, severe unilateral testicular pain.

• Patients may report associated abdominal pain and vomiting.

• Previous episodes may have occurred i.e. intermittent torsion

• Sometimes triggered by trauma.

Examination

Possible clinical signs include:

• Swollen and painful testicle.

• Firm testis

• Horizontal lie or high-riding testis

• Absent cremasteric reflex

TWIST score

• The Testicular Workup for Ischaemia and Suspected Torsion

• This is a validated clinical risk score (by non-urologists) to aid the assessment of patients with testicular pain.

• Scoring:

• testicular swelling (two points)

• hard testis (two points)

• absent cremasteric reflex (one point)

• nausea or vomiting (one point)

• high riding testis (one point)

• The score may be used if there is an unclear diagnosis or to confirm/challenge clinical decision not to perform scrotal exploration.

• Our initial local data shows a correlation between TWIST score and intraoperative findings but there are cases of torsion in the TWIST low-risk group. This suggests that you cannot rely on the TWIST score and it should not replace quality clinical assessment. Further research is ongoing.

Investigations

• The diagnosis of testicular torsion is based on a focussed history and examination.

• A positive urine dip (nitrites and leucocytes) may support an alternate diagnosis such as epididymo-orchitis

• Blood tests do not need to be performed routinely and should not delay scrotal exploration.

• Ultrasound does not reliably exclude testicular torsion. It should not delay scrotal exploration. It may be used to confirm an alternate diagnosis if requested by the Urology team.

If a testicular torsion is suspected based on the history and/or examination findings an urgent scrotal exploration should take place after discussion with the on-call consultant Urologist.

Treatment should not be delayed for an ultrasound to be performed. A normal ultrasound does not exclude testicular torsion.

Differential diagnosis includes infection (epididymo-orchitis), testicular tumour or an incarcerated inguinal hernia.

In children a torted hydatid of Morgagni also causes acute scrotal pain.

A focussed history and examination should identify cases in which testicular torsion is likely or a possibility.

If testicular torsion is suspected, or cannot be excluded, immediate scrotal exploration should be performed. If required a second emergency theatre should be opened or an elective theatre should be paused at the discretion of the theatre co-ordinator, on-call consultant anaesthetist and on-call consultant Urologist.

Any delay in the assessment or management of a patient with testicular pain should be escalated to the Consultant Urologist on-call and site manager.

Scrotal Exploration

The symptomatic side should be explored. If torsion is confirmed orchidopexy or orchidectomy should be performed. Orchidopexy should be performed using 3-point fixation using prolene or PDS sutures. Contralateral orchidopexy should also be performed.

If scrotal exploration finds no torsion but a bell-clapper deformity is present then bilateral fixation should be performed.

If scrotal exploration finds no torsion and no bell-clapper deformity then fixation should not be performed. Contralateral exploration should not be performed.

Management of Children with Testicular pain

Children aged 4 of over

• should be managed as per the pathway outlined above

Children less than 4

• Should be reviewed by the urology middle-grade or SHO on-call before referral to the relevant tertiary centre.

• If Urology unable to see within 30 mins consider direct referral and blue light transfer from ED to paediatric urology unit

For example if possibility of surgical diagnosis e.g. hernia

Awaiting guidance and agreement from paediatric centres. In the meantime cases to be managed on individual basis depending on clinical details and staffing.

Testicular torsion is a surgical emergency. It occurs when the spermatic cord twists and there is interruption of the blood supply to the testis. Prompt diagnosis and surgical intervention is needed to preserve the testis. Delays in presenting to hospital, diagnosis or treatment of torsion adversely affects the chance of salvaging the testis. A systematic review of 1,283 patients showed a 97% testicular salvage rate when surgery was performed within 6 hours. Salvage rates reduce beyond 6-8 hours but are possible up to 24 hours.

There are other causes of acute testicular pain such as infection (epididymo-orchitis), testicular tumour, trauma, torted hydatid of Morgagni and inguino-scrotal hernia which need to be assessed and treated decisively.

Presentation

Testicular torsion is a clinical diagnosis.

History

• Symptoms usually include sudden onset, severe unilateral testicular pain.

• Patients may report associated abdominal pain and vomiting.

• Previous episodes may have occurred i.e. intermittent torsion

• Sometimes triggered by trauma.

Examination

Possible clinical signs include:

• Swollen and painful testicle.

• Firm testis

• Horizontal lie or high-riding testis

• Absent cremasteric reflex

TWIST score

• The Testicular Workup for Ischaemia and Suspected Torsion

• This is a validated clinical risk score (by non-urologists) to aid the assessment of patients with testicular pain.

• Scoring:

• testicular swelling (two points)

• hard testis (two points)

• absent cremasteric reflex (one point)

• nausea or vomiting (one point)

• high riding testis (one point)

• The score may be used if there is an unclear diagnosis or to confirm/challenge clinical decision not to perform scrotal exploration.

• Our initial local data shows a correlation between TWIST score and intraoperative findings but there are cases of torsion in the TWIST low-risk group. This suggests that you cannot rely on the TWIST score and it should not replace quality clinical assessment. Further research is ongoing.

Investigations

• The diagnosis of testicular torsion is based on a focussed history and examination.

• A positive urine dip (nitrites and leucocytes) may support an alternate diagnosis such as epididymo-orchitis

• Blood tests do not need to be performed routinely and should not delay scrotal exploration.

• Ultrasound does not reliably exclude testicular torsion. It should not delay scrotal exploration. It may be used to confirm an alternate diagnosis if requested by the Urology team.

Patients presenting with acute testicular pain less than 24 hours should be referred directly from Emergency department triage to the Urology middle-grade on-call.

If the presentation is unclear the triage nurse should ask for the patient to be reviewed by an emergency department clinician immediately. Such cases would include the possibility of hernia or alternate pathology.

If testicular torsion is suspected, or cannot be excluded, immediate scrotal exploration should be performed. If required a second emergency theatre should be opened or an elective theatre should be paused at the discretion of the theatre co-ordinator, on-call consultant anaesthetist and on-call consultant Urologist.

Any delay in the assessment or management of a patient with testicular pain should be escalated to the Consultant Urologist on-call and site manager.

Scrotal Exploration

The symptomatic side should be explored. If torsion is confirmed orchidopexy or orchidectomy should be performed. Orchidopexy should be performed using 3-point fixation using prolene or PDS sutures. Contralateral orchidopexy should also be performed.

If scrotal exploration finds no torsion but a bell-clapper deformity is present then bilateral fixation should be performed.

If scrotal exploration finds no torsion and no bell-clapper deformity then fixation should not be performed. Contralateral exploration should not be performed.

Management of Children with Testicular pain

Children aged 4 of over

• should be managed as per the pathway outlined above

Children less than 4

• Should be reviewed by the urology middle-grade or SHO on-call before referral to the relevant tertiary centre.

• If Urology unable to see within 30 mins consider direct referral and blue light transfer from ED to paediatric urology unit

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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