Twisted Up: Testicular Torsion, Part 2

Matthew DeLaney, MD, FACEP, FAAEM and Brit Long, MD

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The summary below is from an episode of ERcast: Clinical Perspectives

Testicular torsion is a time-critical ischemic emergency that can present with scrotal pain, abdominal pain, or both. No single history or exam finding rules it out, including the cremasteric reflex, and outcomes are best when detorsion happens within 6 hours.

Testicular Torsion Pitfalls and Management

Unreliable exclusion findings: A present cremasteric reflex does not exclude torsion; roughly 40% of confirmed cases still have it, and Prehn's sign can also mislead clinicians.
Atypical pain presentation: About 20% of patients present with abdominal or flank pain alone, making torsion easy to miss if the scrotum is not examined and documented.
High-yield exam clues: A high-riding, firm, swollen testicle with a horizontal lie strongly raises concern, and a hard tender knot in the spermatic cord is another classic red flag.
TWIST score triage: The TWIST score helps risk-stratify acute testicular pain using swelling, hard testis, nausea or vomiting, high-riding position, and cremasteric findings. We get into how to use the cut points in the episode.
Doppler ultrasound first: Scrotal ultrasound with Doppler is the first-line test, with the whirlpool sign and pseudomass offering especially persuasive evidence even before flow is completely absent.
Salvage window and rescue: Testicular salvage exceeds 90% in the first 6 hours, so confirmed torsion with major surgical delay is a situation for manual detorsion before operative exploration. We walk through when to make that move in the chapter.

Subscribe to ERcast: Clinical Perspectives to listen to the episode.

References:

Rosenberg H, Long B, Keays M. Just the facts: assessment and management of testicular torsion in the emergency department. CJEM. 2021 Nov;23(6):740-743. doi: 10.1007/s43678-021-00189-6. Epub 2021 Aug 18. PMID: 34406643.
Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. PMID: 28953100.
Barbosa JA, Tisea BC, Barayan GA, Rosman BM, Torricelli FCM, Passerotti CC, Srougi M, Retik AB, Hguyen HT. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859–64. PMID: 2310800
Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol. 2016;195(6):1870-1876. PMID: 26835833
Qin KR, Qu LG. Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score. J Urol. 2022;208(1):62-70. PMID: 35238603
Gold DD, Lorber A, Levine H, et al. Door To Detorsion Time Determines Testicular Survival. Urology. 2019;133:211-215. PMID: 31408640

Faculty

Matthew DeLaney, MD, FACEP, FAAEM
Dr. Matthew DeLaney is an emergency medicine physician and educator based in Birmingham, Alabama. A native of Mobile, he earned his medical degree from the University of South Alabama and completed his emergency medicine residency at Maine Medical Center.Dr. DeLaney has experience in both community and academic emergency medicine and is known for his commitment to teaching and medical education. He lives in Birmingham with his wife, Erin, who is also a physician, and their two daughters.
Brit Long, MD
Dr. Brit Long is a Professor of Emergency Medicine at the University of Virginia and an emergency medicine physician with experience in both a community ED and at a military academic center ED. He is the Clinical Editor-in-Chief of emDOCs.His professional interests include medical education, evidence-based medicine, and the FOAMed movement. Outside of work, he enjoys spending time with his wife and two daughters