Testicular torsion is an acute, organ threatening surgical condition. In order to save a testicle, blood flow must be restored as early as possible. Delays in triage, diagnosis, and appropriate intervention must be avoided. These truisms form the foundations of standard of care as well as the decision to operate and the prognosis for testicular function salvage.
Testicular torsion, also called spermatic cord torsion, occurs in males with peak incidence during the neonatal period and at puberty (12-18). It can occur after strenuous exercise, after trauma to the scrotum, or during sleep. The cause of torsion is not completely understood, but certain anatomy causes the testicle to have less fixation in its scrotal attachments, and the muscles involved in normal testicular retraction are often oriented on an angle that initiates twisting when a reflex is elicited. Patients with testicular torsion will often recall similar episodes of discomfort, that were short-lived or less intense prior to the one that has brought them to emergent evaluation and, typically, urgent surgery.
The classic scenario for pubertal presentation of testicular torsion is unilateral severe abdominal, groin, and/or scrotal pain of sudden onset associated with nausea or vomiting. On examination, the patient has scrotal pain, swelling, and redness only on the side of pain. The testicle is tender to palpation and may be hard and raised up (twisting the spermatic cord shortens its length) compared to the uninvolved testicle. Definitive diagnosis by history and physical examination is common, and there are scoring systems for findings that have been validated for use by urologists, ED providers, and even EMTs, that give percentages for certainty. Only in cases in which the diagnosis cannot be made on clinical grounds, a diagnostic ultrasound that further demonstrates the underlying anatomy and blood flow status may be ordered to assist in identifying the problem. When history and physical examination establish a high degree of diagnostic certainty, urologic consultation should be made before a diagnostic ultrasound is pursued.
Injury to the testicle is caused by the decrease in blood supply that is caused by the twisting. Survival of the testicle is dependent on how much time the testicle remains in the twisted state. Because cells in the testicle responsible for sperm production begin to be injured after approximately 1 hour and are irreversibly injured after approximately 6 hours without normal blood flow, treatment of testicular torsion is focused on restoring normal blood flow as early as possible, but certainly before 6 hours. The ways to reduce time that the testicle is without normal blood flow are making as rapid a diagnosis as possible, manually untwisting the testicle (once a diagnosis is made) to restore blood flow temporarily, and/or getting the patient to the operating room for definitive surgical care as soon as possible. Surgery involves assessment of the possibility of testicular salvage and tacking (in place) a viable testicle and the contralateral testicle to prevent future twisting. Testicles that have been twisted long enough to be nonviable are commonly removed.
If treated within 6 hours, there is an excellent chance (90%) of saving the testicle. Within 12 hours the rate decreases to 50%, within 24 hours is 10%, and after 24 hours the rate approaches 0. The surgery is relatively simple and, frankly, mandatory to save the testicle. All that is needed is a surgical consult and work up to be operated on within an hour or so thereafter. Therefore, the failure to diagnose, work up and subsequently treat testicular torsion will result in the loss of the testicle.
Testicular torsion medical expert witness specialties include urology, emergency medicine, pediatric emergency medicine, and pediatric urology.