Ep 111 – Testicular torsion

Testicular torsion is a urological emergency that usually affects young men, and a high index of suspicion is vital to ensure prompt diagnosis and management. A history and physical examination consistent with testicular torsion requires immediate surgical assessment for scrotal exploration – and if the initial examination suggests testicular torsion, the surgical approach should take precedence over other diagnostic tests. In this episode, Dr Roger Henderson discusses what to look for when diagnosing this condition, the importance of prompt treatment and the options available in primary care.

Key references

1. Sheth KR, et al. J Urol. 2016;195(6):1870-1876. doi: 10.1016/j.juro.2016.01.101.
2. Vasconcelos-Castro S, Soares-Oliveira M. J Pediatr Surg. 2020;55(9):1933-1935. doi: 10.1016/j.jpedsurg.2019.08.014.
3. Sharp VJ, et al. Am Fam Physician. 2013;88(12):835-840.
4. NHS England. Commissioning guide: Management of Paediatric Torsion. https://www.england.nhs.uk/mids-east/wp-content/uploads/sites/7/2018/03/torsion-commissioning-guide.pdf
5. Blaivas M, Brannam L. Emerg Med North Am. 2004;22(3):723-48, ix. doi: 10.1016/j.emc.2004.04.002.
6. NHS England. GIRFT Children and Young People: Testicular torsion pathway. https://gettingitrightfirsttime.co.uk/wp-content/uploads/2024/02/Paediatric-testicular-torsion-pathway-guide-FINAL-V1-February-2024.pdf.

Key take-home points

• There are two types of testicular torsion, intra- and extra-vaginal, with intra-vaginal being the most common type.
• Although it may occur at any age, testicular torsion does not usually affect older men.
• It has a peak incidence in teenagers aged 13 to 16.
• In young men the annual incidence has been estimated at 1 in 4,000.
• Torsion may occur then resolve spontaneously in some cases.
• Any patient with a history of undescended testes who presents with sudden abdominal pain should be evaluated for possible torsion, as should any young man with abdominal pain.
• The typical presentation is of sudden severe pain in one testis that may have occurred after exercise.
• Patients presenting with symptoms lasting less than 6 hours have the greatest chance of testicular viability.
• If symptoms have been present more than 24 hours before treatment, testicular salvage results are poor.
• If there is a high suspicion of torsion, normal clinical findings should not preclude further investigation.
• The TWIST score is a good way of evaluating possible testicular torsion.
• Any investigations should not delay treatment.
• It may be possible to manually reduce a testicular torsion but this is only a temporising measure.
• Surgical treatment is the definitive treatment of testicular torsion.
• Testicular salvage rates are 90–100% with surgical correction within 6 hours of torsion onset, but only 10% at 24 hours.