Testicular torsion occurs when a testis rotates on the vascular pedicle, producing sharp pain secondary to ischemia. A final diagnosis of testicular torsion will be made in 20% to 25% of children presenting with acute scrotal pain. The differential diagnosis includes torsion of the testicular appendage, epididymitis, incarcerated inguinal hernia, and trauma. Clinicians should not be misled by a history of testicular trauma, which is often obtained in children with testicular torsion.

Time is of the essence, because many patients present after enduring ischemic pain for 12 or more hours. Studies suggest that the gonadal salvage rate is lower in the adolescent patient, which is felt to be secondary to patient delay in seeking medical attention (1). It is for this reason that manual detorsion of the testis can be quite useful as a temporizing therapeutic maneuver until surgeon and operating room availability is confirmed. Surgery should follow for definitive open surgical reduction and orchiopexy.

Testicular torsion occurs in children with testes that are not adequately fixed by the tunica vaginalis to the posterior scrotal wall. This “bell-clapper” deformity enables the testicle and spermatic cord to twist, causing either partial or complete obstruction of venous outflow and/or arterial inflow via the spermatic vessels. It is thought that after 8 hours of warm ischemia, there is an increased likelihood of testicular atrophy. However, gonadal salvage may still be possible after a period of prolonged symptoms if the obstruction is incomplete or intermittent.

Testicular torsion results in the triad of acute diffuse scrotal pain, a high-riding testicle, and an absent cremasteric reflex. This triad occurs because twisting of the spermatic cord results in a retraction of the testis back toward the pubic tubercle. The twisting rotation shortens the cremasteric muscle fibers, leaving them unable to exert their normal pulling action, which forms the basis for the valuable cremasteric reflex test. Stroking the inner thigh causes stimulation that results in the cremasteric reflex, which is a sudden brisk upward deflection of the testicle (Fig. 96.1). This sign, if present, almost always excludes spermatic cord torsion in the acute setting (2). However, a case report does describe the presence of a cremasteric reflex in a patient with surgically confirmed testicular torsion, cites two other such cases, and thus serves as a reminder that this diagnosis should not be excluded entirely on one criterion alone (3). It must be stressed, however, that many normal male patients will not have a positive cremasteric reflex; hence this sign is helpful only if it is present. The deflection must be upward, and it must be significant (1 to 2 cm) to have the optimal reliability. Stroking the thigh may produce a wrinkling of the scrotal skin as the underlying dartos muscle contracts, and the inexperienced observer may mistake this for a cremasteric reflex. When testicular torsion is present, examination of the testis will reveal a tense and extremely tender gonad, with no ability to discriminate between the epididymis and the testis. On occasion, if the patient has been symptomatic for longer than 1 day, the pain may lessen over time as the infarction proceeds.

Testicular torsion is a clinical diagnosis, and the patient should be seen as quickly as possible by a urologist. For the patient with classic torsion who is seen and evaluated in the emergency department (ED) setting, no further testing is needed, and operative reduction and orchiopexy must occur. In many instances, with experienced ED and urology staff, the child is directed immediately to the operating room (OR), with no further testing. If the OR team is not assembled or OR time is not immediately available, manual detorsion can be performed to “buy time” until the OR and personnel
become available. Often the child presents with an equivocal history or the pain has lasted more than 12 hours, making the physical examination less reliable (4). In this setting the physicians, after a careful history and physical examination, often opt to obtain a Doppler flow ultrasound study to confirm that there is blood flow to the testis (5). With the improved spatial resolution and accuracy of Doppler sonography, this is a reasonable option. It is essential, however, that the sonographers be experienced in the use of such imaging technology, that the flow be clearly demonstrated within the testis itself, and that
a clear and unequivocal arterial waveform be demonstrated (Fig. 96.2A). False-positive tests for blood flow to the testes have been reported that upon closer inspection are shown to represent flow to the inflamed scrotal wall (Fig. 96.2B).