Testicular torsion (pediatrics): Clinical sciences

Testicular torsion occurs when the spermatic cord becomes twisted, which impairs blood flow to and from the ipsilateral testis. This condition is a surgical emergency that must be addressed quickly in order to prevent permanent ischemic damage to the testicle. Several factors can increase a patient’s susceptibility to testicular torsion, such as an abnormal fixation of the testicle within the scrotum, as well as rapid growth, increased vascularity, inflammation, and trauma. Based on history and physical examination findings, you can categorize testicular torsion as an acute or intermittent condition.

Now, if a pediatric patient presents with a chief concern suggesting testicular torsion, first perform an ABCDE assessment to determine if the patient is unstable or stable. If your patient is unstable, stabilize the airway, breathing, and circulation. Next, obtain IV access and give IV fluids. Don’t forget to put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry.

Alright, let’s go back to the ABCDE assessment and look at stable patients. If your patient is stable, first obtain a focused history and physical examination.

Now, let’s look at patients who report a sudden onset of severe unilateral scrotal or testicular pain. This pain will often awaken the patient in the middle of the night or early morning. There might also be nausea and vomiting associated with the pain. The physical exam will reveal scrotal erythema, induration, or edema. Additionally, the affected testicle may appear to “ride higher” in the scrotum, or it could have a transverse orientation.

You might also notice an absent cremasteric reflex on the affected side, which can be elicited by stroking your patient’s inner thigh. Usually, this stimulates the cremaster muscle to contract and pull the testicle upward, but the reflex is often absent on the affected side when torsion is present. These findings are highly suggestive of acute testicular torsion!

Here’s a clinical pearl! Epididymitis can masquerade as testicular torsion, since it also presents with pain and tenderness of the scrotum or testicle. However, epididymitis is usually caused by infection, and patients frequently report a more gradual onset of pain. Also, unlike testicular torsion, the cremasteric reflex is usually present. Additionally, patients with epididymitis usually experience pain relief when the testicle is elevated, which is also known as a positive Prehn sign.

Now, as soon as you suspect testicular torsion, obtain an emergent surgical consult! You can also attempt manual detorsion to restore blood flow to the testicle while awaiting surgery, as long as your patient can tolerate the pain. But don’t let your attempt delay surgical intervention! To perform manual detorsion, rotate the testicle in an “open book” motion, meaning in a medial-to-lateral direction. You’ll know whether you’re successful if the maneuver causes the testicle to rest in a lower position within the scrotum and if your patient experiences pain relief.

While medial-to-lateral rotation is commonly successful, if it doesn’t result in detorsion, you can attempt manual detorsion in a lateral-to-medial direction. Keep in mind that even if manual detorsion is successful, emergency surgery is still indicated, since your attempt may result in only a partial detorsion!

Surgical treatment involves rapid exploration of the scrotum for detorsion and fixation; or, if the testicle is nonviable, orchiectomy is indicated. Contralateral orchiopexy can be considered at the time of surgery, since the anatomic anomalies that increase the risk of testicular torsion usually occur bilaterally.