Manual Detorsion of the Testes

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Torsion of the testes is a surgical emergency, since it causes strangulation of gonadal blood supply with subsequent testicular necrosis and atrophy. ^{[1, 2]} Acute scrotal swelling in children indicates torsion of the testes until proven otherwise.

Testicular torsion is a true urologic emergency; a delay in diagnosis and management can lead to loss of the testicle. In approximately two thirds of patients, history and physical examination are sufficient to make an accurate diagnosis. If testicular torsion is suspected, notify a surgeon, urologist or pediatric surgeon and arrange for diagnostic imaging to make a definitive diagnosis as soon as possible. In adolescent males, testicular torsion is the most frequent cause of testicle loss.

Testicular torsion occurs more commonly in patients who have an inappropriately high attachment of the tunica vaginalis. This allows the testicle to rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly is called the bell clapper deformity and results in the long axis of the testicle becoming oriented transversely rather than cephalocaudal, as shown in the image below. The bell clapper deformity is present in approximately 12% of males; 40% of them are affected in both testicles.

Extravaginal testicular torsion that occurs in newborns cannot be treated by manual detorsion.

Testicular torsion is commonly observed in males younger than 30 years, with a peak at 12-18 years. The incidence of torsion in males younger than 25 years is approximately 1 in 4000. ^[3] Torsion more often involves the left testicle. The etiologic factors involved in intravaginal testicular torsion include congenital anomaly, bell clapper deformity, undescended testicle, sexual arousal or activity, exercise, active cremasteric reflex, and cold weather.

Testicular torsion typically presents with a history of sudden onset of severe, unilateral scrotal pain. Most patients have a history of previous episodes of intermittent testicular pain that resolved (detorsion) spontaneously. Torsion can occur with activity or may develop during sleep. The main signs at presentation are 1) scrotal erythema and swelling, and 2) nausea, vomiting, or both.

Other causes of acute scrotal pain that should be ruled out before manual detorsion is considered include the following:

Orchitis

Epididymitis, epididymo-orchitis

Torsion of the testicular or epididymal appendages

Trauma-related causes

Hydrocele

Testicular tumor

Idiopathic scrotal edema

In older boys, the classic presentation of testicular torsion is the sudden onset of severe testicular pain followed by inguinal and/or scrotal swelling. Pain may lessen as the necrosis becomes more complete.

In cases of reduced pain or resolution of the episode at presentation without manual detorsion, necrosis should be suspected. A surgical evaluation should be performed, and detorsion applied as indicated.

Testicular salvage is most likely if the duration of torsion is less than 6-8 hours. If 24 hours or more elapse, testicular necrosis develops in most patients. Manual detorsion is contraindicated if the duration of torsion is more than 6 hours.

Manual detorsion is performed without local or general anesthesia.

Mild analgesic medications may be administered when testicular torsion has been diagnosed. However, most practitioners prefer that no analgesics are administered so that the examination is not biased.

No special equipment is required for manual detorsion of the testes.

Doppler ultrasound examination should be performed at the time of presentation and after manual detorsion to confirm the reestablishment of vascular flow to the testes. ^{[4, 5, 6, 7]}

The patient should be standing or supine.

The practitioner should be positioned in front of the patient.

In patients with testicular torsion, the affected testis generally is twisted inward (medially). Although generally considered uncommon, torsion resulting from lateral rotation of the testicle has been reported in up to one third of cases. ^[6]

With torsion of the left testis, hold the testicle with the right thumb and forefinger and then rotate the testicle clockwise 180 degrees. This manipulation may need to be repeated 2-3 times, because testicular torsion may involve rotations of 180-720 degrees. These repeated attempts should be guided by resolution of pain and return to normal anatomy.

For torsion of the right testicle, the procedure is similar except that the testicle is held using the left thumb and forefinger and the testicle is rotated in a counterclockwise direction.

Manual detorsion is successful in 30-70% of patients and is evident by the immediate relief experienced by the patient. Owing to this large range in the success of manual detorsion, it is recommended to use Doppler ultrasound after the manipulation is complete to confirm the state of testicular vascularization. After successful manual detorsion, surgical exploration remains a necessity because residual torsion poses a continued risk to testicular viability. ^[8]

In patients with testicular torsion, the affected testis generally is twisted inward (medially). The clinician can easily recall which direction to rotate a torsed testicle (depending on which side is affected) by comparing the action to opening the spine of a book.

Manual testicular detorsion has no complications.

Manual detorsion of the testes is usually difficult because of acute pain during manipulation. Nonoperative manual detorsion is not a substitute for surgical exploration.

Kapoor S. Testicular torsion: a race against time. Int J Clin Pract. 2008 May. 62(5):821-7. [Medline].

Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15. 88 (12):835-40. [Medline].

Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006 Nov 15. 74(10):1739-43. [Medline].

Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006 May. 25(5):563-74. [Medline].

Garel L, Dubois J, Azzie G, Filiatrault D, Grignon A, Yazbeck S. Preoperative manual detorsion of the spermatic cord with Doppler ultrasound monitoring in patients with intravaginal acute testicular torsion. Pediatr Radiol. 2000 Jan. 30(1):41-4. [Medline].

Cannon ML, Finger MJ, Bulas DI. Manual testicular detorsion aided by color Doppler ultrasonography. J Ultrasound Med. 1995 May. 14(5):407-9. [Medline].

Güneş M, Umul M, Çelik AO, Armağan HH, Değirmenci B. A novel approach for manual de-torsion of an atypical (outward) testicular torsion with bedside Doppler ultrasonography guidance. Can Urol Assoc J. 2015 Sep-Oct. 9 (9-10):E676-8. [Medline].

Saxena AK, Castellani C, Ruttenstock EM, Hollwarth ME. Testicular torsion: a 15-year single-centre clinical and histological analysis. Acta Paediatr. 2012 Jul. 101(7):e282-6. [Medline].

Amulya K Saxena, MD, PhD Consultant Pediatric Surgeon, Department of Pediatric Surgery, Chelsea Children’s Hospital, Chelsea and Westminster Healthcare NHS Fdn Trust, Imperial College London, UK

Amulya K Saxena, MD, PhD is a member of the following medical societies: International Pediatric Endosurgery Group, British Association of Paediatric Surgeons, European Paediatric Surgeons’ Association, German Society of Surgery, German Association of Pediatric Surgeons, Tissue Engineering and Regenerative Medicine International Society, Austrian Society for Pediatric and Adolescent Surgery

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Manual Detorsion of the Testes

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