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Testicular torsion: current evaluation and management.

Annually, 4.5 out of every 100,000 males under 25 years of age will have a testicular torsion (DaJusta, Granberg, Villanueva, & Baker, 2013). There is a bimodal age distribution, with a peak in the neonatal period and another in the peripubertal period (Jefferies, Cox, Gupta, & Proctor, 2015; Riccabona et al., 2015; Sharp, Kieran, & Arlen, 2013). In the pediatric population, testicular torsion has an annual incidence of 3.8 per 100,000 pediatric patients (Zhao, Lautz, Meeks, & Maizels, 2011), with the peak incidence occurring between ages 12 to 16 years (Kadish & Bolte, 1998; Lian, Ong, Chiang, Rai, & Nah, 2015; Riccabona et al., 2015). Approximately 10% of testicular torsions occur in neonates; of these, 70% are believed to occur in utero (prenatal torsion), with the remaining 30% occurring within the first 30 days of life (postnatal torsion) (see Figure 1) (Basta, Courtier, Phelps, Copp, & MacKenzie, 2015). Neonatal testicular torsion affects both sides equally. Greater than 10% of cases occur bilaterally in a synchronous manner (Basta et al., 2015; Jensen, Elleboek, Rasmussen, & Qvist, 2015). Testicular torsion in the neonatal period differs in its etiology and presentation than that occurring in children and adolescents, and pediatric providers must be aware of these differences.


Neonatal torsion is the result of inadequate fixation of the gubernaculum, the structure that leads the testis into the scrotum during testicular descent and anchors the testis to the inferior aspect of the scrotum (Basta et al., 2015; Sharp et al., 2013). Neonatal torsion is an extravaginal torsion, involving the entire spermatic cord, including the processus vaginalis (Basta et al., 2015; Jefferies et al., 2015; Riccabona et al., 2015; Sharp et al., 2013).

Testicular torsion beyond the neonatal period (1 month of age and older) is an intravaginal torsion. Intravaginal torsion involves twisting of the spermatic cord within the tunica vaginalis (but does not include the tunica vaginalis) and more commonly affects the left side (Basta et al., 2015; Jefferies et al., 2015; Sharp et al., 2013). The most common etiology for intravaginal testicular torsion is the "bell clapper deformity." Normally, the tunica vaginalis attaches to the posterior surface of the testicle; however, some patients have an inappropriately high attachment of the tunica vaginalis, the bell clapper deformity, which allows the testicle to rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). The bell clapper deformity is a congenital anomaly thought to be present in approximately 12% of males and is the only known anatomic risk factor for intravaginal torsion (Caesar & Kaplan, 1994). Although only 2% of patients present with bilateral torsion, the anatomic abnormality that predisposes to torsion is presumed to be bilateral, and nearly 80% of patients have this anomaly bilaterally (Kapoor, 2008; Martin & Rushton, 2014; Sharp et al., 2013).

Risk Factors

The only known anatomic risk factor for intravaginal testicular torsion is the bell clapper deformity (Caesar & Kaplan, 1994; DaJusta et al., 2013). Despite this, it is not well understood how the bell clapper deformity arises (DaJusta et al., 2013). Precipitating factors likely include trauma, exercise, increased testicular volume, history of cryptorchidism, presence of testicular tumors, horizontal position of the testes, and the presence of a long intrascrotal spermatic cord (Cuckow & Frank, 2000; Gomes Dde, Vidal, Foeppel, Faria, & Saito, 2015). However, it is estimated that only 4% of cases are associated with a history of trauma (Gomes Dde et al., 2015; Leape, 1967). A seasonal variation in testicular torsion has been suggested in studies dating back to 1982, with a proposed theory that colder weather can cause contraction of the cre-master muscle and/or tunica dartos and produce testicular torsion (Chen, Lin, & Yang, 2013; Gomes Dde et al., 2015; Karakan et al., 2015; Shukla, Kelly, Daly, & Guiney, 1982).

The anatomic risk factor associated with neonatal torsion is lack of fixation of the gubernaculum. However, other risk factors for neonatal torsion include high birth weight, late birth week, breech presentation, and trauma from labor (Basta et al., 2015; Mano, Livne, Nevo, Sivan, & Ben-Meir, 2013; Sharp et al., 2013).

Cases of familial testicular torsion have raised the possibility of a genetic basis for testicular torsion. The INSL3 knockout mouse model has intra-abdominal testes and spontaneous testicular torsion, with the risk being higher in adolescent mice. INSL3 is produced by the Leydig cells in humans and mice. In the mouse, INSL3 is involved in the masculinization and enlargement of the gubernaculum, which precedes testicular development and scrotal fixation (Sozubir et al., 2010).

Outcomes of Testicular Torsion

During testis torsion, the testicle twists spontaneously on the spermatic cord, causing venous occlusion and engorgement with subsequent arterial ischemia and infarction. Experimental evidence indicates that a 720[degrees] twist is required to compromise flow through the testicular artery and result in ischemia. Clinically, however, pain lasting more than four to eight hours is highly associated with lack of testicular viability unless detorsion is performed (Chen et al., 2013; DaJusta et al., 2013; Lian et al., 2015; Sheth et al., 2016). The testis salvage rate approaches 100% in patients who undergo detorsion within six hours of the onset of pain. However, there is only a 20% viability rate if detorsion occurs greater than 12 hours, and virtually no viability if detorsion is delayed more than 24 hours (American Urological Association [AUA], 2016).

The time from presentation to definitive treatment is vital in preserving testicular function (Chen et al., 2013; Sharp et al., 2013). As early as two hours after the torsion event, there is damage to spermatogenesis, and after four to six hours, spermatogenesis is likely destroyed. If the torsion persists for eight hours or longer without detorsion, the endocrine function is damaged as well, and after 10 to 12 hours, there is testicular necrosis--a nonviable testis (Riccabona et al., 2015).

At the time of surgical intervention, one-third of testes will be deemed nonviable and orchiectomy performed (Cost, Bush, Barber, Huang, & Baker, 2011). Even if the testis is deemed salvageable, there may be irreversible and ongoing testicular damage after surgery, resulting in diminished testicular size after healing and possible adverse effects on the contralateral testis (DaJusta et al., 2013). Prenatal torsion is often associated with a nonviable testis, particularly be cause 70% occur prenatally and 30% occur postnatally, and thus, irreversible ischemic damage has likely occurred prior to diagnosis in the majority of patients (AUA, 2016; Basta et al., 2015; Jensen et al., 2015).

Clinical Presentation

Providers who triage and evaluate a male with acute scrotal pain must maintain a high index of suspicion in order to rapidly and effectively treat and prevent negative sequelae of testicular torsion. However, acute scrotal pain has a broad differential, with only 10% to 15% of acute scrotal disease in children due to testicular torsion (Sharp et al., 2013; Sheth et al., 2016). The differential diagnoses of scrotal swelling and/or scrotal pain in a pediatric patient includes epididymo-orchitis, epididymitis, torsion of the appendix epididymis, torsion of the appendix testis, testicular tumor, scrotal soft tissue trauma, spermatic cord hematoma, scrotal cellulitis, inguinal hernia, hydrocele, varicocele, ureteral distention, lower back pain, peritonitis, and hematologic disorders, such as leukemia or lymphoma (Gordhan & Sadeghi-Nejad, 2015; Kadish & Bolte, 1998; Pepe et al., 2015; Sharp et al., 2013). Thus, the goal of the provider is to differentiate testicular torsion from these other causes of testicular pain.

Patients with testicular torsion classically present with acute onset, severe, diffuse unilateral testicular pain that may be associated with nausea and vomiting (see Table 1) (Chen et al., 2013; DaJusta et al., 2013; Gordhan & Sadeghi-Nejad, 2015; Jefferies et al., 2015; Kadish & Bolte, 1998; Riccabona et al., 2015; Sharp et al., 2013; Sheth et al., 2016). These individuals are uncomfortable with and without movement, and will often walk with a wide-based gait. Their history may also be notable for fever, urinary symptoms, trauma, and strenuous physical activity, and up to 20% of patients will have abdominal pain (Mano et al., 2013; Sharp et al., 2013). When asked, the child will often point to the scrotum as the source of the pain; however, if asked to point with one finger to the area of maximal pain, will point to the testis itself. Examination and imaging may reveal a high-riding testicle, horizontal orientation of the testicle, palpable twist in the spermatic cord, ipsilateral scrotal skin induration, erythema, or warmth, as well as absent or decreased blood flow on ultra-sonography (Gordhan & Sadeghi-Nejad, 2015; Jefferies et al., 2015; Riccabona et al., 2015; Sharp et al., 2013; Sheth et al., 2016). An absent cremasteric reflex is highly suggestive of testicular torsion, but this has varied between 20% to 100% in prior studies (Beni-Israel, Goldman, Bar Chaim, & Kozer, 2010; Boettcher, Bergholz, Krebs, Wenke, & Aronson, 2012; Boettcher et al., 2013; Jefferies et al., 2015; Sharp et al., 2013; Sheth et al., 2016).

In younger males or those with developmental delays, the history and presentation may be different. These children may refer to testicular/scrotal pain as abdominal pain and may not be able to clearly identify the location of the pain. In such individuals, the history may be less useful, and a high index of suspicion is necessary to prompt further evaluation of the child's complaints. Given the time-dependent impact of testicular torsion, it is important that providers, including nurses, nurse practitioners, and physician assistants who care for children, be aware of the clinical presentation and have a high index of suspicion when triaging and evaluating a male child with scrotal pain.

Providers treating children need to be comfortable performing an examination of a child with a painful scrotum because the diagnosis of testicular torsion is first and foremost a clinical diagnosis. When examining the child with an acute scrotum, one should begin on the contralateral side to differentiate between the testis and the epididymis. Prior to starting the examination of the affected side, the provider should first ask the patient to point to the area of maximum pain. The examination should start away from this area initially because inciting pain at the beginning of the examination may prevent further examination and localization of the area of maximal pain due to the child's fear of experiencing further pain. The examiner should assess for the presence or absence of a cremasteric reflex by tickling the child's inner thigh and assessing for retraction of the testis. Presence of the cremasteric reflex on the asymptomatic side and absence on the side of scrotal pain is suggestive of testicular torsion.

In contrast to testicular torsion in an older child, neonatal torsion presents as a painless scrotal swelling with or without acute inflammation (Gordhan & Sadeghi-Nejad, 2015; Jefferies et al., 2015; Sharp et al., 2013; Sheth et al., 2016). Prenatal torsion classically presents as a firm, non-tender scrotal mass in a neonate (Jefferies et al., 2015; Mano et al., 2013). The infant is asymptomatic; therefore, the torsion is typically identified during a routine examination of the genitalia at birth or during a diaper change.


Scrotal pain, swelling, or mass is a urologic emergency until proven otherwise (Jefferies et al., 2015; Kadish & Bolte, 1998). A thorough history and physical examination are essential to determine clinical management. Urinalysis should be performed to rule out genitourinary infection (Gordhan & Sadeghi-Nejad, 2015). In cases where the history and examination are strongly suggestive of testicular torsion, emergent surgical intervention is indicated. However, in cases where the examination may be limited due to testicular swelling and pain, further evaluation with testicular ultrasound with Doppler may be obtained if readily available. The request for a testicular ultrasound with Doppler and its interpretation by a radiologist may result in a time delay; thus, investigators have sought to develop risk scoring systems based on signs and symptoms only to aid in the triage of patients presenting with scrotal pain.

Barbosa et al. (2013) devised and validated the Testicular Workup for Ischemia and Suspected Testicular Torsion (TWIST) score. The TWIST scoring system assigned a summed TWIST score (range 0 to 7 points) based on the absence (0 points) or presence of the following 5 variables: testicular swelling (2 points), hard testicle (2 points), absent cremasteric reflex (1 point), nausea/vomiting (1 point), and high-riding testis (1 point) (see Table 2). The authors concluded that patients at high risk for testicular torsion (TWIST score greater than or equal to 5) could proceed straight to the operating room without testicular ultrasound because the positive predictive value (PPV) was 100% (Barbosa et al., 2013).

For individuals with an intermediate TWIST score of 3 to 4, testicular ultrasound with Doppler is required, and for individuals with low TWIST score of less than or equal to 2, a testicular ultrasound with Doppler is not required because the negative predictive value (NPV) was 100% (Barbosa et al., 2013; Sheth et al., 2016). The initial evaluation and validation were performed with urologists. However, urologists are often not the providers who conduct the initial evaluation of the pediatric patient with scrotal pain. Sheth et al. (2016) used the TWIST scoring system with patients evaluated by emergency medical technicians and demonstrated that the TWIST score could be highly predictive in more sexually mature males; TWIST scores of 0 had a NPV of 100%, and a high-risk TWIST score in sexually mature males had a PPV of 100% (Sheth et al., 2016). Given these findings, it could be utilized as a rapid way to clinically evaluate a patient with acute scrotal pain prior to the evaluation by a pediatric urologist/surgeon. Thus, given its broad provider applicability, we believe it may be useful for nurse practitioners and physician assistants to use in the urology office or emergency care setting.

Equivocal cases should undergo imaging to determine the etiology with color Doppler sonography (CDS), the first-line radiologic test to evaluate a patient with an equivocal acute scrotum after clinical assessment (DaJusta et al., 2013; Jefferies et al., 2015; Riccabona et al., 2015). Ultrasound features that suggest testicular torsion include 1) complete or partial hypoechoic pattern in early torsion followed by heterogeneous or hyperechoic appearance; 2) image of twisted vessels, sometimes described as "whirlpool" or "snail shell;" and 3) absent, reduced, or reversed diastolic arterial flow on Doppler (see Figure 2) (Lian et al., 2015). Studies show that CDS is highly sensitive (88.9% to 100%) and specific (97% to 98.8%), with a 1% false negative rate (Kadish & Bolte, 1998; Sharp et al., 2013; Sheth et al., 2016). However, CDS is highly operator-dependent and can have inaccurate interpretations (Gordhan & Sadeghi-Nejad, 2015). CDS has also been used to predict the likelihood of testicular salvage, with cases that appear heterogeneous on ultrasound being 100% predictive of testicular loss at surgical exploration (Kaye et al., 2008).

High-resolution ultrasonography (HRUS) is another imaging modality whose utility has been investigated in the setting of testicular torsion. HRUS was found to have 97% sensitivity and 99% specificity compared to CDS, with a sensitivity of 76%, albeit for linear or twist configuration of the spermatic cord (Kalfa et al., 2007). Despite these findings, to our knowledge, HRUS has not been investigated further. Testicular torsion can be ruled out if a normal spermatic cord (homogenous, linear, and without thickening) and symmetric, normal testicles (both parenchyma and perfusion) are seen on ultrasound (Riccabona et al., 2015).

Other imaging options include radionuclide imaging and near-infrared spectroscopy (NIRS). Radionuclide imaging involves intravenous isotope injection and subsequent imaging of the scrotum, which can be used to differentiate torsion from epididymitis. Epididymitis results in "hot spots" caused by increased perfusion near the testicle versus "cold spots" caused by decreased perfusion seen in torsion. However, the lack of general availability and potential diagnostic delay make this less favorable in the acute setting (Riccabona et al., 2015; Sharp et al., 2013). NIRS is a newer technology that could be used to rapidly diagnose torsion by using infrared light to obtain continuous, noninvasive, transcutaneous monitoring of deep tissue oxygen saturation (percentage of StO2). NIRS may save time in bypassing radiology technicians and radiologists needed for ultrasonography. It has been studied in animal models and adults, with some studies and a case report demonstrating lower testicular oxygen saturation on the affected testis (Aydogdu et al., 2012; Burgu et al., 2013; Capraro et al., 2007; Hallacoglu et al., 2009; Shadgan, Fareghi, Stothers, Macnab, & Kajbafzadeh, 2014). Conversely, a 2013 study by Schoenfeld, Capraro, Blank, Coute, and Visintainer demonstrated no difference in saturation levels between healthy and torsed testicles in patients with surgically confirmed torsion.

Management of Testicular Torsion

Prompt evaluation is critical given that significant ischemic damage can occur in four to eight hours, resulting in deleterious effects on spermatogenesis (Sharp et al., 2013). The approximate salvage rates vary according to the time length of torsion, with 90% to 100% salvageable if surgical exploration is performed within six hours of symptom onset, 50% if greater than 12 hours, and less than 10% if greater than 24 hours. However, it is difficult to predict testicular viability, and surgical exploration is still indicated despite timing (Chen et al., 2013; Sharp et al., 2013), particularly because protection of the contralateral testis is one goal of surgical exploration. Up to 16% of patients have testicular abnormalities that could predispose them to future torsion (Al-Zahem & Shun, 2006). If history and physical examination suggest testicular torsion, imaging studies should not be pursued, and the patient should undergo immediate surgical exploration. If the history and physical are strongly suggestive of torsion, and ultrasonography findings are negative, patients should still undergo surgical exploration because false normal ultrasound evaluations have been reported (Jefferies et al., 2015; Sharp et al., 2013).

Manual detorsion can be attempted if surgical exploration is not immediately available or while preparing for surgery, but this is a temporizing measure only, and surgical exploration should still be performed (Gordhan & Sadeghi-Nejad, 2015; Riccabona et al., 2015; Sharp et al., 2013). Manual detorsion is usually attempted after adequate analgesia to allow for manipulation of the testicle. The testis should be rotated from medially to laterally, like the opening of a book, to relieve the torsion. The endpoint of manual detorsion is alleviation of pain, with Doppler ultrasonography confirming restored vascular flow. However, analgesia may make it difficult to assess pain relief, and ultrasonographic evaluation may be complicated due to hyperemia, altered vascular flow (Sharp et al., 2013), and a lack of ability to assure the manual detorsion has been completely successful.

Surgically, the trans-scrotal approach is generally used, with detorsion of the affected spermatic cord performed until no twists are visible and testicular viability is assessed (Sharp et al., 2013). Typically, after detorsion of the testis, a warm-soaked sponge is placed around the testis, and attention addressed to the contralateral scrotal orchiopexy, and reassessment of the affected testis after the contralateral orchiopexy has been performed. Intraoperative assessment of viability includes the gross appearance of the testis, presence or absence of testicular bleeding upon incising the tunica albuginea, and re-establishment of blood flow and color after detorsion (Lian et al., 2015). If the testicle is assessed to be nonviable, then orchiectomy is performed, with rates ranging between 9.1% to 56%, depending upon the time of surgical exploration, with later exploration having higher rates of orchiectomy (see Figure 3) (Chen et al., 2013; Jefferies et al., 2015; Sharp et al., 2013; Sheth et al., 2016). Prophylactic contralateral orchiopexy should be performed regardless of the affected testicle's viability (Jefferies et al., 2015; Sharp et al., 2013). Despite this measure, it is still possible to have ipsilateral recurrence of the torsion. In a 2006 study by Mor et al., recurrent testicular torsion occurred in eight of 179 patients, with four involving the ipsilateral testicle and the other four involving the contralateral testicle.

Neonatal unilateral torsion management has been controversial. Neonatal torsion is more commonly an extravaginal torsion involving the spermatic cord, testis, and tunica vaginalis versus the more common intravaginal torsion involving only the spermatic cord and testis. Neonatal torsion is subdivided into prenatal, prior to birth, and postnatal --birth to 30 days of life (DaJusta et al., 2013). Testicular viability in neonatal torsion is poor, with reported salvage rates of approximately 9% and approaching zero if the event was prenatal (Riccabona et al., 2015; Sharp et al., 2013). The timing of surgery is debated in unilateral torsion; some support early intervention, and others prefer a delayed approach.

The rationale behind early management includes the risk of asynchronous contralateral torsion, which can occur in up to one-third of cases (Baglaj & Carachi, 2007; Yerkes et al., 2005). Those who support a delayed surgical approach argue that the risk of anesthesia is too great, and the neonatal torsed testis is very often unsalvageable (Catre, Lopes, Viana, & Cabrita, 2015; DaJusta et al., 2013). However, in a 2007 Mayo Clinic study of over 90,000 pediatric anesthesia cases, the risk of anesthesia-related cardiac arrest in children less than 18 years old was very low (0.3 per 10,000) for non-cardiac surgery cases and an American Society of Anesthesiologists physical status (ASA PS) I or II (Flick et al., 2007). In the same Mayo Clinic study of the risk for neonates 0 to 30 days old, four cardiac arrests occurred in 1,014, with all four cases being an ASA PS of IV or V (Flick et al., 2007). Moreover, assessing neonatal anesthesia risk has been shown to be difficult, and current risk assessment tools are poor at predicting perioperative outcomes (Udupa et al., 2014). In light of this, more tools to assess perioperative risk have been developed in the past year with potentially more accuracy (Nasr, DiNardo, & Faraoni, 2016; Subramanyam, Yeramaneni, Hossain, Anneken, & Varughese, 2016).

In cases of unilateral neonatal torsion, the affected testis is often removed to prevent infection and to minimize the risk of antibodies against testicular tissue (Jensen et al., 2015). Contralateral orchiopexy is generally recommended due to the theoretical increased risk of torsion, but this must be weighed against the risk of complications, which can approach 18% (Jensen et al., 2015; Riccabona et al., 2015; Sharp et al., 2013).

Synchronous bilateral neonatal torsion has been reported in up to 17% of cases, and is typically managed with immediate surgical exploration and orchiopexy given the risk of anorchia (Abraham, Charles, Gera, & Srinivasjois, 2015; DaJusta et al., 2013; Jensen et al., 2015). Neonatal torsion is treated as a surgical emergency, given the poor salvage rates of the affected testicle. Again, contralateral orchiopexy is often performed given the risk of asynchronous bilateral torsion (Basta et al., 2015; Jensen et al., 2015).

A number of novel surgical and pharmacologic interventions for the management of testicular torsion are under investigation. Testicular compartment syndrome is a hypothesis where, after detorsing the testicle, testicular reperfusion can lead to edema, which in the inelastic tunica albuginea may increase the testicular pressure, leading to hypoperfusion and ischemic injury (Kutikov et al., 2008; Moritoki et al., 2011; Watson, Bartkowski, & Nelson, 2015). Novel surgical techniques have been explored in both animal models and patients to address testicular compartment syndrome, including incising the tunica albuginea with or without patching it with tunica vaginalis (Jozsa et al., 2016; Kutikov et al., 2008; Quintaes, Tatsuo, Paulo, Musso, & Boasquevisque, 2013). Other emerging surgical techniques include testicular prosthesis placement at the time of orchiectomy of the torsed testicle (Bush & Bagrodia, 2012). A recent study by Peycelon et al. (2016) examined testicular prosthesis placement for all causes and found torsion to be one of the most common reasons for prosthesis placement. Complications among subjects in this study included prosthesis extrusion, infection and ascension, and an overall complication rate of 10.5%.

Attention has been given to ischemic reperfusion injury in long-term testicular injury. This theory stems from the idea that the recruitment of neutrophils and the creation of reactive oxygen species (ROS) result in DNA damage and germ cell apoptosis (Altavilla et al., 2012). A multitude of pharmaceuticals and compounds have been studied in animal models, including sildenafil, rosuvastatin, poly (adenosine diphosphate-ribose) polymerase (PARP) inhibitors, ginkgo biloba, and pomegranate juice (Atilgan et al., 2014; DaJusta et al., 2013; Shimizu et al., 2016). Another approach to prevent ischemic reperfusion injury has been to utilize a technique called postconditioning. This entails short bursts of reperfusion interspersed with periods of ischemia before fully reperfusing the affected testicle. A handful of studies investigated this in animal models, all of which have shown promising results in decreasing pro-inflammatory, proapoptotic, and/or decreased histologic damage (Minutoli et al., 2013; Ozkisacik et al., 2012; Shimizu et al., 2010; Zhang, Lv, & Tang, 2016). Shimizu et al. (2010) demonstrated that postconditioning in rats reduced malondialdehyde and myeloperoxidase, markers of oxidative damage and neutrophil infiltration respectively.

Implications and Long-Term Outcomes

Long-term outcomes surrounding testicular torsion generally concern reproductive function. Even after preservation of the affected testis, atrophy has been reported to occur in 12% to 68% of patients, and patients with pain greater than one day or heterogeneous echogenicity by preoperative ultrasound are more likely to have atrophy (Lian et al., 2015). A recent study by Gielchinsky et al. (2016) examined pregnancy rates after testicular torsion treated with either orchiopexy or orchiectomy. Pregnancy rates were found to be 90.2% and 90.9% respectively, both of which fall into the accepted pregnancy rate in the general population of 82% to 92%.

FER/semen analysis after testicular torsion has been associated with abnormal semen parameters when compared to normal standard values, including sperm count, motility, and morphology (DaJusta et al., 2013). Arap et al. (2007) compared fertility parameters in normal healthy controls to those with a history of testicular torsion repaired with either orchiopexy or orchiectomy. All groups were shown to be abnormal, with orchiopexy having the worst scores and control having the best scores. Further, anti-sperm antibody levels were abnormal in patients with torsion but were not significantly different from healthy controls (Arap et al., 2007). Romeo et al. (2010) investigated hormonal function in patients with testicular torsion who underwent detorsion and orchiopexy or orchiectomy. In both the orchiopexy and orchiectomy groups, FSH, LH, and testosterone levels were normal, but inhibin B levels were reduced compared to controls (Romeo et al., 2010). Another factor potentially impacting fertility in patients post-torsion could be poor vas deferens contractility, which was shown in rat models to be poor after torsion (Karacay et al., 2011). Chronic pain is another long-term concern. A 2015 study found that the risk of chronic orchalgia in children who underwent scrotal exploration for acute scrotal pain occurs in 1.4% of cases (Hart et al., 2015).

Another relatively unexplored long-term concern is the psychological impact of orchiectomy. In addition, it is not clear if the impact is different for males with a history of neonatal torsion versus torsion as an older child. In an effort to gain further insight into this topic, we reviewed all cases of testicular torsion occurring in infants through 18 years of age who underwent surgery at our institution between October 26, 2006, and December 31, 2015 (Hazeltine, Panza, & Ellsworth, 2016). Additionally, all cases of testicular prosthesis placement for this time period were reviewed.

During this timeframe, four infants were explored and underwent orchiectomy for testicular torsion, and 25 children and adolescents underwent surgical exploration, two of whom underwent orchiectomy. There were eight testicular prosthesis placements for testicular torsion, with the age at time of prosthesis placement ranging from 14 to 39 years, and none placed at the time of testicular torsion. The age of torsion for those undergoing prosthesis placement varied; three of the eight (37.5%) individuals had a neonatal torsion, two (25%) had torsion as a child, two (25%) as an adolescent, and one (12.5%) where age was not identified. These data demonstrate the rate of testicular prosthesis placement is similar between torsion that occurred in neonatal and child/adolescent periods. Moreover, data indicate that testicular prosthesis placement is not typically performed at the time of testicular torsion. However, patients and their families could be counseled regarding future testicular prosthesis placement. Nurse practitioners and physician assistants often see postoperative patients; therefore, a discussion regarding testicular prosthesis placement and timing thereof can be performed during postoperative visits.

Prompt diagnosis and treatment are critical for the preservation of testicular tissue. The importance of this is reflected in the legalities associated with testicular torsion. Testicular torsion was the third most common diagnosis of a malpractice claim involving children aged 12 to 17 years from 1985-2000 in the Physician Insurers Association of America database of closed pediatric claims originating in the emergency department and urgent care center (Selbst, Friedman, & Singh, 2005). Testicular torsion was the fourth most commonly misdiagnosed condition reported in a 2010 review (Brown, McCarthy, Kelen, & Levy, 2010). The rate of testicular loss can approach 100% if a diagnosis is missed (Sharp et al., 2013). In 52 malpractice suits involving testicular torsion from 2000-2013, 96% of claims were negligence claims regarding failure of diagnosis, of which 65% were incorrectly diagnosed as epididymitis. Emergency medicine physicians were the most commonly sued physicians (48%), with urologists being the next most common (23%) (Colaco, Heavner, Sunaryo, & Terlecki, 2015).


Urologic nurses, nurse practitioners, and physician assistants must be aware of the presentation, timing, and evaluation of testicular torsion because they may receive calls from primary care providers to triage the pediatric patient with a painful scrotum or be involved in the evaluation in the emergency room or clinic. Pediatric testicular torsion is a surgical emergency that requires a thorough history and physical examination, and is, at the outset, a clinical diagnosis.

Testicular torsion can occur neonatally, peripubertally, or as an adult. In the pediatric population, approximately 90% of cases occur peripubertally. In a neonate, 70% of torsion occurs prior to birth. Neonatal testicular torsion often presents as a hard mass found on routine examination. Surgical management typically involves orchiectomy with a contralateral orchiopexy. The only known risk factor for peripubertal and adult torsion is the bell clapper deformity, which predisposes to intravaginal testicular torsion. Peripubertal/adolescent and adult testicular torsion classically presents as acute onset severe scrotal pain, with nausea and vomiting, a high and horizontal testicular lie, and an absent cremasteric reflex.

A prompt diagnosis and definitive surgical management are essential in males of any age to preserve the affected testicle. In patients with a high clinical suspicion, emergent surgical management is warranted. Emerging therapies are focused on antioxidant properties to prevent testicular damage by reactive oxygen species. The major implication of testicular loss is future fertility; however, more studies are needed to further elucidate the association between testicular torsion and fertility. Lastly, an understanding of the impact of testicular torsion may help urologic nurses, nurse practitioners, and physician assistants counsel parents/caretakers of such affected children/adolescents and adult males. Testicular prosthesis placement is an option that can be offered to adolescent and adult patients.



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Max Hazeltine, BS, is a fourth-year medical student, University of Massachusetts Medical School, Worcester, MA.

Audrey Panza, CPNP, RN, CPN, is a Pediatric Urology Nurse Practitioner, UMass Memorial Medical Center, Worcester, MA.

Pamela Ellsworth, MD, is Chief, Division of Pediatric Urology, Nemours Children's Hospital, Orlando, FL.

Caption: Figure 1. Testicular Torsion throughout Childhood

Caption: Figure 2. Ultrasound Demonstrating Enlarged, Heterogeneous, Torsed Testis, and Normal Appearing Contralateral Testis

Caption: Figure 3. Intra-Operative Photograph of Ischemic Testis after Detorsion
Table 1.
Acute Scrotum Differential

                        Testicular          Epididymitis


Age                    Neonates and      Post-pubertal (2)
                     peripubertal (2)
Onset                Acute (1,2,3,4)      Subacute (1,2,3)
Fever                     + (3)                + (3)
Nausea/vomiting          + (3,4)               + (3)
Dysuria                   - (3)                + (3)
History of sexual         - (3)               + (1,3)
History of trauma         + (3)                + (3)

                   Physical Examination

Febrile                   + (3)               + (2,3)
Testicular lie        Abnormal (1,3)         Normal (3)
cremasteric reflex    Absent (1,2,3)      Present (1,2,3)
Location of           Diffuse (2,3)     Epididymis (1,2,3,4)
Other                  High riding,            Warm,
                         swollen          indurated (2,3)
                      testis (1,2,4)

                        Torsion Appendix


Age                     Pre-pubertal (2)

Onset                 Acute-subacute (2,3)
Fever                         + (3)
Nausea/vomiting               - (3)
Dysuria                       - (3)
History of sexual             - (3)
History of trauma             + (3)

           Physical Examination

Febrile                       - (3)
Testicular lie             Normal (3)
cremasteric reflex        Present (2,3)
Location of           Superior pole (2,3,4)
Other                "Blue dot sign" (2,3,4)

Notes: +++ = always/very common (67-100%); ++ = usually (34-66%);
+ = occasionally (0-33%); (-) = never/rare.

(1) Gordhan & sadeghi-Nejad, 2015.

(2) Jefferies, Cox, Gupta, & Proctor, 2015.

(3) Kadish & Bolte, 1998.

(4) Sharp, Kiernan, & Arlen, 2013.

Table 2.
Testicular Workup for Ischemia and Suspected Torsion (TWIST)

Scoring System

                      Present   Absent

Testicular swelling      2        0
Hard testicle            2        0
Absent cremasteric       1        0
Nausea/vomiting          1        0
High riding testis       1        0
Total score                 __/7

Sources: Barbosa et al., 2013; Sheth et al., 2016.
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Author:Hazeltine, Max; Panza, Audrey; Ellsworth, Pamela
Publication:Urologic Nursing
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Date:Mar 1, 2017
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