Testicular Torsion Pitfalls and Challenges
Testicular Torsion Pitfalls and Challenges
By Larry Mellick, MD, MS, FAAP, FACEP, Editor-in-Chief; Professor of Emergency Medicine and Pediatrics, Medical College of Georgia, Augusta
A common diagnostic dilemma for emergency medicine physicians is the patient who presents with a painful testicle. Frequently, the presentations of the various conditions that cause scrotal pain and most frequently testicular torsion fail to "conform to the accepted clinical picture."1 Accurately sorting through the various conditions that can cause a painful testicle can be challenging. In fact, experts admit that their initial clinical impressions frequently are flawed.1,2,3 Even authors who continue to express confidence in the physical examination report a significant number of patients with misdiagnoses of their testicular torsion (12.5%).4
Conditions that commonly present as a painful testicle range from kidney stone pain referred to the scrotum to a testicular torsion. Various diagnostic tools and modalities, including physical examination, doppler ultrasound, nuclear scintigraphy, and surgical exploration, are available to assist with sorting through the diagnostic possibilities.
The most time-limited diagnosis is testicular torsion, which is the twisting of the spermatic cord with subsequent loss of blood flow to the testis as well as impaired venous drainage. Unless the condition is recognized and managed in a timely manner, the resulting edema and ischemia eventually end in testicular necrosis.
Although the timely and accurate diagnosis of testicular cancer or epididymitis is clinically important, torsion of the testicle is the condition that presents with the clock ticking. In fact, the phrase "time is testicle" is commonly used. The failure to diagnose testicular torsion in a timely manner results in significant morbidity to the patient and generally includes loss of the endangered testicle. In adolescent males 12 to 17 years of age, testicular torsion is the third most common cause of a malpractice lawsuit.5
Difficulties Diagnosing Testicular Torsion
So, just how reliable is the physical examination in the diagnosis? The answer is that it is not reliable. The overlap of physical findings between testicular torsion and epididymitis, the condition most commonly mistakenly confused for torsion, is impressive. Although clinically it may be possible to make the diagnosis of torsion or epididymitis without an ultrasound or a nuclear scan, the health care provider needs to understand that a gamble is being taken. The stakes are high; and unfortunately, when the clinician is wrong, both the patient and the physician can lose big.
Although the onset of pain in testicular torsion frequently is sudden, it can be more gradual in nature and suggestive of epididymitis.1 In one series, although 90.7% of testicular torsion patients had a sudden onset, almost 60% of epididymitis patients also reported a rapid onset.6
The loss of the cremasteric reflex is commonly described with testicular torsion. Nevertheless, it remains present in a significant number of patients and cannot be relied upon to rule out torsion of the testicle. Van Glabeke et al reported that 40% (10 of 25) of testicular torsion patients demonstrated a persistence of the cremasteric reflex.6 Murphy et al reported a normal cremasteric reflex present in three of the eight patients requiring orchiectomy due to necrotic testicles.2 In a published abstract, Paul et al reported that the cremasteric reflex was present in 12% of their small series of 17 testicular torsion patients; and these authors described the cremasteric reflex as "suboptimal" in diagnosing testicular torsion.7 In a moderately sized series reported by Ciftci et al, the cremasteric reflex was reported as present in 8% of patients with testicular torsion.8 Eaton et al described a series of patients with intermittent torsion in which the cremasteric reflex was present in 20% (3 of 15) of patients.9 Karmazyn reported that 10% of their series of 31 patients with testicular torsion had a cremasteric reflex.10
Pain around the upper pole of the testicle or epididymis is thought to be consistent with epididymitis, but it also occurs with torsion. In a review of 543 surgical explorations of children and adolescents, Van Glabeke et al reported the pain was restricted to the upper pole of the testis in 40.8% of patients with torsion of the testicular appendage and almost 18.7% of patients with testicular torsion.6 The epididymis also can be enlarged on ultrasound in patients with testicular torsion. Karmazyn et al reported that 43% of the children with testicular torsion had a swollen epididymis as compared to 77% of the children with epididymitis and torsion of the testicular appendix.10
Scrotal edema and testicular swelling are common in torsion of the testicle, appendix of the testicle, and in patients with epididymitis.1,4,6,11
Nausea and vomiting occur more frequently with torsion of the testicle. However, the signs and symptoms often are not reported and they also can occur with epididymitis.4 Sessions et al reported nausea and vomiting in only 60% (90 of 150) patients with testicular torsion.12 Lyonis et al reported nausea and vomiting in 62.8% of patients with testicular torsion and 12.9% of patients with epididymo-orchitis.11
Although the lie of the testicle in torsion is frequently transverse, a vertical orientation is also common. In a small series by Kadish et al, a normal lie was described in 54% of the testicular torsion patients.3 Ciftci et al found 17% of patients with testicular torsion had a normal or vertical orientation of the testicle.8 Eaton et al reported a horizontal lie in 46% of their patients with intermittent testicular torsion.9 Murphy et al described an abnormal position of the torted testicle in 52% of their 31 patients with testicular torsion.2 In that series, abnormal testicular position was reported as a horizontal lie in 26% of those patients.2 Karmazyn et al reported an "abnormal orientation" in 21 of 41 patients with testicular torsion.10
Complications and Testicular Survival
Just as with the reliability of the physical examination, testicular survival is an issue more complicated than what frequently is stated. It is commonly taught that the torted testicle has six hours before becoming nonviable. Although there have been dead testicles noted at surgery or atrophy at follow-up when symptoms have been present for fewer than six hours,2,12 many papers and series in the literature describe longer time periods after which significant percentages of testicles have gone on to survival.2,4,11-18 Significant numbers of reports describe survival up to 12 to 24 hours.
Bayne et al reported that mean pain symptom duration in boys who were transferred but subsequently did not undergo orchiectomy (loss of the testicle) was 9.8 hours. The mathematical mean would represent that many of their patients with surviving testicles were beyond that timeframe.17 Lyronis et al reported that the mean duration of pain at presentation was 11.4 hours, when the testis was salvaged by detorsion.11
There are even reports of survival beyond 24 hours. In an earlier report by Klingerman et al, the longest interval to survival was 48 hours.14 In the series reported by Cavusoglu, the mean duration of pain at presentation was 1.35 days (range 12 hours to 3 days) when the testis was salvaged by detorsion.18 In the series of 200 patients reported by Sessions et al, symptom duration before presentation for evaluation was 0.5 hours to 6 days (median 5 hours) in all orchiopexy cases or surviving testicles.12 In the small series by Arce et al, the testicles of all six patients survived and one patient had a torsion of 540 degrees for 18 hours and another 360 degrees for 12-14 hours.15 Hegarty et al described a small series of 33 patients with testicular torsion. 16 Six patients with pain for more than 24 hours had viable testes; 2 patients had subsequent testicular atrophy.16
And while the degrees of torsion matter, survival is documented to have occurred in patients with up to 1,080 degrees of torsion.12 In that light, there must be other factors, such as thickness of the cord and tightness of the twist, that contribute to the prolonged survival or quick demise of a testicle. Bentley et al described a series of patients with spermatic cord torsion and preserved testis perfusion. In their small series of 4 patients who presented with testicular torsion and preserved perfusion, the testicles were torsed 180, 360, 540, and 720 degrees.19 Karmazyn reported normal flow on ultrasound in 10 of 41 patients with torsion and in 3 of these patients the spermatic cord was twisted from 540 to 1,440 degrees.10 The preserved perfusion explains one reason why doppler ultrasound sometimes can be misleading and clinicians still must rely on their clinical instinct when all signs and symptoms otherwise point toward a testicular torsion. The authors conclude that the "diagnosis of testicular torsion remains a complex, often confusing challenge to the clinician."10
There are two important take-home lessons regarding the diagnosis and management of testicular torsions. The first is that "an absolute dependence on symptoms and signs will lead to testicular torsion being misdiagnosed."2 The second lesson is that emergency physicians cannot and should not write off testicles as unsalvageable that present after six or more hours from onset of symptoms.
1. Leape LL. Torsion of the testis. Invitation to error. JAMA 1967;200:669-672.
2. Murphy FL, et al. Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum. Pediatr Surg Int 2006;22:413-416.
3. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998;102:73-76.
4. Mushtaq I, et al. Retrospective review of paediatric patients with acute scrotum. ANZ J Surg 2003;73:55-58.
5. Selbst SM, et al. Epidemiology and etiology of malpractice lawsuits involving children in U.S. emergency departments and urgent care centers. Pediatr Emerg Care 2005;21:165-169.
6. Van Glabeke E, et al. Acute scrotal pain in children: Results of 543 surgical explorations. Pediatr Surg Int 1999;15:353-357.
7. Paul EM, et al. How useful is the cremasteric reflex in diagnosing testicular torsion? J Am Coll Surg 2004;199:101. .
8. Ciftci AO, et al. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediat Surg 2004;14:333-8.
9. Eaton SH, et al. Intermittent testicular torsion: Diagnostic features and management outcomes. J Urol 2005;174:1532-1535; discussion 1535.
10. Karmazyn B, et al. Clinical and sonographic criteria of acute scrotum in children: A retrospective study of 172 boys. Pediatr Radiol 2005;35:302-310.
11. Lyronis ID, et al. Acute scrotumetiology, clinical presentation and seasonal variation. Indian J Pediatr 2009;76:407-410. Epub 2009 Feb 10.
12. Sessions AE, et al. Testicular torsion: Direction, degree, duration and disinformation. J Urol 2003;169:663-665.
13. Allan WR, Brown RB. Torsion of the testis: A review of 58 cases. Br Med J 1966;1:1396-1397.
14. Klingerman JJ, Nourse MH. Torsion of the spermatic cord. JAMA 1967;200:673-675.
15. Arce JD, et al. Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: A key to the diagnosis. Pediatr Radiol 2002;32:485-491. Epub 2002 Apr 10.
16. Hegarty PK, et al. Exploration of the acute scrotum: A retrospective analysis of 100 consecutive cases. Ir J Med Sci 2001;170:181-182.
17. Bayne AP, et al. Factors associated with delayed treatment of acute testicular torsionDo demographics or interhospital transfer matter? J Urol 2010;184:1743-7.
18. Cavusoglu YH, et al. Acute scrotumEtiology and management. Indian J Pediatr 2005;72:201-203.
19. Bentley DF, et al. Spermatic cord torsion with preserved testis perfusion: Initial anatomical observations. J Urol 2004;172:2373-2376.
For more information, contact:
Andrew Garlisi, MD, MPH, MBA, VAQSF, University Hospitals Geauga Medical Center, Chardon, OH. Phone: (330) 656-9304. Fax: (330) 656-5901. E-mail: [email protected]
Gregory P. Moore, MD, JD, Emergency Department, Madigan Army Medical Center, Tacoma, WA. E-mail: [email protected].
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