Testicular torsion (pediatrics): Clinical sciences

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Introduction0:00–0:39

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.

Unstable Patient0:39–1:06

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.

Stable Patient1:06–1:18

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.

Acute Testicular Torsion1:18–4:21

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.Here’s a high yield fact!
The “bell clapper” deformity is a common anatomic variant that predisposes patients to testicular torsion. In this deformity, the tunica vaginalis attaches more proximally, which allows the testicle to move freely within the scrotum and potentially twist, causing an intravaginal torsion.
The “bell-clapper” deformity typically occurs bilaterally, so affected individuals often require a contralateral orchiopexy.Let’s switch gears and discuss patients who report episodes of recurrent scrotal pain, with intervals of spontaneous symptom resolution.

Intermittent Testicular Torsion4:21–6:41

In this case, the physical exam commonly reveals that the affected testicle lies in a transverse orientation. You may also detect excessive testicular mobility.
These findings should make you suspect intermittent testicular torsion, so as a next step, obtain a color-flow Doppler ultrasound of the scrotum to assess blood flow to the testicle.
If the scrotal ultrasound is normal and confirms adequate blood flow to the testicle, consider an alternative diagnosis, such as torsion to the appendix testis.
This self-limited condition causes acute scrotal pain and is characterized by the blue-dot sign, which is a bluish discoloration of scrotal skin that indicates infarction of the appendix testis.
You should also consider Henoch-Schonlein purpura, a condition associated with scrotal pain, swelling, and erythema of the scrotum and spermatic cord.
These patients will typically have additional symptoms, like abdominal pain and purpuric rash.On the other hand, if the ultrasound reveals coiling of the spermatic cord, known as the “whirlpool sign,” or if you see decreased blood flow to the testis, diagnose intermittent testicular torsion.
As soon as you make the diagnosis, obtain an emergent surgical consultation for surgical exploration with detorsion and fixation; or, if the testis is not viable, an orchiectomy.
Additionally, your patient may also require contralateral orchiopexy. Here’s a final clinical pearl!
While testicular torsion can be seen at any age, it is often seen during puberty and during the adolescent years. Also, prenatal torsion can be seen in newborns.
Unlike torsion in older patients, in prenatal torsion, the spermatic cord typically twists proximal to the tunica vaginalis.
This process is known as extravaginal torsion and usually occurs during testicular descent in utero. The newborn exam classically reveals a hard, nontender mass in the hemiscrotum, and an underlying dark discoloration of the scrotal skin.
These signs represent infarction due to prenatal testicular torsion, and the testis is generally not salvageable.Alright, as a quick recap… If a patient presents with a chief concern suggesting testicular torsion, obtain a focused history and physical examination.

Review6:41–7:55

If they had an acute sudden onset of unilateral testicular pain, and physical exam reveals scrotal erythema, edema, and induration; a high-riding or transversely-oriented testicle; and possibly an absent cremasteric reflex, diagnose acute testicular torsion.
Next, obtain an emergent surgical consult for exploration, detorsion, and fixation; or possibly orchiectomy or contralateral orchiopexy.
While awaiting surgery, you may attempt manual detorsion to restore testicular blood flow. However, if the patient presents with recurrent, self-resolving episodes of scrotal pain, and an exam confirms a transversely oriented testicle with excessive mobility, obtain a color-flow Doppler ultrasound.
If the ultrasound demonstrates the “whirlpool sign” or decreased blood flow to the testicle, diagnose intermittent testicular torsion and obtain emergent surgical consultation for exploration, detorsion and fixation; or possibly orchiectomy or contralateral orchiopexy.