Testicular torsion - Revision history

Rossdonaldson1: Reverted edits by Danbot (talk) to last revision by Patricklin

2026-03-25T18:58:01Z

Reverted edits by Danbot (talk) to last revision by Patricklin

Danbot: Strip excess bold text - keep only critical safety emphasis

2026-03-22T09:23:04Z

Strip excess bold text - keep only critical safety emphasis

← Older revision		Revision as of 09:23, 22 March 2026
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	==Types==		==Types==
	*~~'''~~Intravaginal~~'''~~ (most common) — within tunica vaginalis; associated with "bell clapper" deformity		*Intravaginal (most common) — within tunica vaginalis; associated with "bell clapper" deformity
	*~~'''~~Extravaginal~~'''~~ — entire testis and tunica rotate; typically neonatal		*Extravaginal — entire testis and tunica rotate; typically neonatal

	==Clinical Features==		==Clinical Features==
	*~~'''~~Sudden onset~~'''~~, severe unilateral testicular pain		*Sudden onset, severe unilateral testicular pain
	*Nausea, vomiting (very common)		*Nausea, vomiting (very common)
	*~~'''~~High-riding~~'''~~ testicle with ~~'''~~horizontal lie~~'''~~		*High-riding testicle with horizontal lie
	*Absent ~~'''~~cremasteric reflex~~'''~~ on affected side (most sensitive PE finding; >99% sensitivity in some studies, but absence does not rule out torsion)		*Absent cremasteric reflex on affected side (most sensitive PE finding; >99% sensitivity in some studies, but absence does not rule out torsion)
	*Diffuse testicular swelling and tenderness		*Diffuse testicular swelling and tenderness
	*Negative Prehn sign (elevation of testis does not relieve pain) — unreliable		*Negative Prehn sign (elevation of testis does not relieve pain) — unreliable
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	==Differential Diagnosis==		==Differential Diagnosis==
	*[[Epididymitis]] / [[Epididymo-orchitis]]		*[[Epididymitis]] / [[Epididymo-orchitis]]
	*Torsion of appendix testis (~~'''~~blue dot sign~~'''~~)		*Torsion of appendix testis (blue dot sign)
	*[[Inguinal hernia]] (incarcerated)		*[[Inguinal hernia]] (incarcerated)
	*Testicular tumor		*Testicular tumor
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	==Evaluation==		==Evaluation==
	*'''Clinical diagnosis''' — high suspicion = immediate urology consult; do NOT delay for imaging		*'''Clinical diagnosis''' — high suspicion = immediate urology consult; do NOT delay for imaging
	*~~'''~~Doppler ultrasound~~'''~~ — if diagnosis uncertain<ref name="beni">Beni-Israel T, et al. Clinical predictors for testicular torsion as seen in the pediatric ED. ''Am J Emerg Med''. 2010;28(7):786-789. PMID 20837253.</ref>		*Doppler ultrasound — if diagnosis uncertain<ref name="beni">Beni-Israel T, et al. Clinical predictors for testicular torsion as seen in the pediatric ED. ''Am J Emerg Med''. 2010;28(7):786-789. PMID 20837253.</ref>
	**Decreased or absent blood flow to affected testis		**Decreased or absent blood flow to affected testis
	**Sensitivity ~88-100%, specificity ~90-100%		**Sensitivity ~88-100%, specificity ~90-100%
	**Normal flow does NOT completely exclude torsion (intermittent or early)		**Normal flow does NOT completely exclude torsion (intermittent or early)
	**~~'''~~If high clinical suspicion, proceed to OR despite normal ultrasound~~'''~~		**If high clinical suspicion, proceed to OR despite normal ultrasound
	*~~'''~~Urinalysis~~'''~~ — typically normal in torsion (pyuria suggests [[Epididymitis\|epididymitis]])		*Urinalysis — typically normal in torsion (pyuria suggests [[Epididymitis\|epididymitis]])
	*TWIST score (Testicular Workup for Ischemia and Suspected Torsion) can risk-stratify in pediatrics		*TWIST score (Testicular Workup for Ischemia and Suspected Torsion) can risk-stratify in pediatrics

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	===Manual Detorsion===		===Manual Detorsion===
	*Attempt if surgical intervention will be delayed		*Attempt if surgical intervention will be delayed
	*~~'''~~Open the book~~'''~~ technique: rotate the affected testicle medial-to-lateral (as opening a book)		*Open the book technique: rotate the affected testicle medial-to-lateral (as opening a book)
	**Typically requires 1-3 full rotations (360-1080 degrees)		**Typically requires 1-3 full rotations (360-1080 degrees)
	*Successful detorsion: immediate pain relief and return of normal testicular position		*Successful detorsion: immediate pain relief and return of normal testicular position
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	===Surgical Management===		===Surgical Management===
	*~~'''~~Emergent urology consultation~~'''~~ for surgical exploration and orchidopexy		*Emergent urology consultation for surgical exploration and orchidopexy
	*Bilateral orchidopexy performed (bell clapper deformity is bilateral in ~80%)		*Bilateral orchidopexy performed (bell clapper deformity is bilateral in ~80%)
	*If testis is nonviable: orchiectomy		*If testis is nonviable: orchiectomy
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	==Disposition==		==Disposition==
	*~~'''~~All suspected testicular torsion requires emergent urology consultation and OR~~'''~~		*All suspected testicular torsion requires emergent urology consultation and OR
	*Do not discharge without urology evaluation		*Do not discharge without urology evaluation

Danbot: Major expansion: manual detorsion technique, TWIST score, imaging caveats, peer-reviewed references

2026-03-21T18:33:20Z

Major expansion: manual detorsion technique, TWIST score, imaging caveats, peer-reviewed references

Show changes

Danbot: Add MedicationDose entry (lidocaine cord block) with SMW annotations

2026-03-20T18:56:01Z

Add MedicationDose entry (lidocaine cord block) with SMW annotations

@@ Line 100: / Line 100: @@
 #If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
 #*In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed
 ==Disposition==

Patricklin at 00:46, 21 November 2023

2023-11-21T00:46:27Z

← Older revision		Revision as of 00:46, 21 November 2023
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	[[File:Figure 28 01 03.jpg\|thumb\|Testicular anatomy]]		[[File:Figure 28 01 03.jpg\|thumb\|Testicular anatomy]]
	[[File:Illu testis surface.jpg\|thumb\|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]]		[[File:Illu testis surface.jpg\|thumb\|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]]
	*~~Half~~ occur during sleep		*Must consider as a ddx in all acute scrotal pain
			**May lead to testicular ischemia and subsequent infertility
			*A clear precipitating factor is not necessary identified; half occur during sleep
	*Bimodal incidence		*Bimodal incidence
	**First peak in first year of life		**First peak in first year of life
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	===Risk factors===		===Risk factors===
			*Mechanical: Exertional/exercise, trauma
			*Testicular masses
	*Undescended testicle		*Undescended testicle
	*Bell-clapper deformity		*Bell-clapper deformity


	'''Salvage Rates for Detorsion Times'''		'''Salvage Rates for Detorsion Times'''
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	**May have previous similar intermittent, self-resolving episodes		**May have previous similar intermittent, self-resolving episodes
	**May present after scrotal trauma with persistent pain		**May present after scrotal trauma with persistent pain
			**May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain
	*Physical exam:		*Physical exam:
	**Swollen, high-riding testis		**Swollen, tender, high-riding testis
	**Transverse testicular lie		**Transverse testicular lie
	**Absent cremasteric reflex on affected side (99% sensitivity)		**Absent cremasteric reflex on affected side (99% sensitivity)
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	==Management==		==Management==
	*Manual detorsion (temporizing measure)		*Manual detorsion (temporizing measure)
			**Typically done if surgical management is not immediately available
	*Urological consultation for detorsion and orchipexy		*Urological consultation for detorsion and orchipexy
			**Surgical exploration is the gold standard; without surgery, difficult to determine if manual detorsion has worked

	===Manual Detorsion===		===Manual Detorsion===
	*Not definitive treatment		*Not definitive treatment. Temporizing measure if urologist not immediately available
	**Temporizing measure if urologist not immediately available		*May require conscious sedation or parenteral [[analgesia]] if severe pain is anticipated
	~~#Provide~~ parenteral [[analgesia]] or perform cord block ~~(grasp~~ cord at external ring and inject 10 mL [[lidocaine]] directly into cord)		#May perform cord block
			#*Grasp spermatic cord as it enters scrotum, track up to external ring, create skin wheal, and inject 10 mL [[lidocaine]] directly into the anterior, lateral, medial portions of cord <ref>Gordon J, Rifenburg RP. Spermatic Cord Anesthesia Block: An Old Technique Re-imaged. West J Emerg Med. 2016 Nov;17(6):811-813. doi: 10.5811/westjem.2016.8.31017. Epub 2016 Sep 13. PMID: 27833695; PMCID: PMC5102614.</ref>
	#"Open the book" by twisting testicle outward and laterally		#"Open the book" by twisting testicle outward and laterally
	#*Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction		#*Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
	#Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases		#Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases
	#If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction		#If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
			#*In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed

	==Disposition==		==Disposition==

Rossdonaldson1: /* Clinical Features */

2020-06-04T20:19:14Z

Clinical Features

← Older revision		Revision as of 20:19, 4 June 2020
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	**Abrupt onset testicular pain associated with nausea or [[vomiting]]		**Abrupt onset testicular pain associated with nausea or [[vomiting]]
	**May have previous similar intermittent, self-resolving episodes		**May have previous similar intermittent, self-resolving episodes
	*May present after scrotal trauma with persistent pain		**May present after scrotal trauma with persistent pain
	**Physical exam:		*Physical exam:
	**Swollen, high-riding testis		**Swollen, high-riding testis
	**Transverse testicular lie		**Transverse testicular lie

Rossdonaldson1: /* Evaluation */

2020-06-04T20:18:42Z

Evaluation

← Older revision		Revision as of 20:18, 4 June 2020
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	*NPV 100% when <2 points (Suggesting clinical clearance)<ref>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.</ref>		*NPV 100% when <2 points (Suggesting clinical clearance)<ref>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.</ref>
	*Scores from 2-5 patients require U/S for further assessment		*Scores from 2-5 patients require U/S for further assessment

			===Diagnosis===
			*[[testicular ultrasound\|Ultrasound]]
			**Only indicated for equivocal cases
			**Unilateral absence of blood flow

	==Management==		==Management==

Rossdonaldson1: /* Clinical Features */

2020-06-04T20:18:21Z

Clinical Features

← Older revision		Revision as of 20:18, 4 June 2020
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	**Abrupt onset testicular pain associated with nausea or [[vomiting]]		**Abrupt onset testicular pain associated with nausea or [[vomiting]]
	**May have previous similar intermittent, self-resolving episodes		**May have previous similar intermittent, self-resolving episodes
	*Physical exam:		*May present after scrotal trauma with persistent pain
			**Physical exam:
	**Swollen, high-riding testis		**Swollen, high-riding testis
	**Transverse testicular lie		**Transverse testicular lie
	**Absent cremasteric reflex on affected side (99% sensitivity)		**Absent cremasteric reflex on affected side (99% sensitivity)
	*[[testicular ultrasound\|Ultrasound]]
	**Only indicated for equivocal cases
	**Unilateral absence of blood flow

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1: /* Background */

2020-06-04T20:17:51Z

Background

← Older revision		Revision as of 20:17, 4 June 2020
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	[[File:Figure 28 01 03.jpg\|thumb\|Testicular anatomy]]		[[File:Figure 28 01 03.jpg\|thumb\|Testicular anatomy]]
	[[File:Illu testis surface.jpg\|thumb\|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]]		[[File:Illu testis surface.jpg\|thumb\|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]]
			*Half occur during sleep
	*Bimodal incidence		*Bimodal incidence
	**First peak in first year of life		**First peak in first year of life

Rossdonaldson1: /* Background */

2020-06-04T20:17:26Z

Background

← Older revision		Revision as of 20:17, 4 June 2020
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	==Background==		==Background==
			[[File:Gray1144.png\|thumb\|Scrotal anatomy]]
			[[File:Figure 28 01 03.jpg\|thumb\|Testicular anatomy]]
	[[File:Illu testis surface.jpg\|thumb\|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]]		[[File:Illu testis surface.jpg\|thumb\|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]]
	~~[[File:Figure 28 01 03.jpg\|thumb\|Diagram of inner structures of testicles]]~~
	*Bimodal incidence		*Bimodal incidence
	**First peak in first year of life		**First peak in first year of life
	**Second peak at puberty		**Second peak at puberty
	*Risk factors
	**Undescended testicle		===Risk factors===
	**Bell-clapper deformity		*Undescended testicle
	*Half occur during sleep		*Bell-clapper deformity
	*May present after scrotal trauma with persistent pain

	'''Salvage Rates for Detorsion Times'''		'''Salvage Rates for Detorsion Times'''