Evidence-Based Diagnosis And Treatment Of Torsion Of The Spermatic Cord In The Pediatric Patient
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Evidence-Based Diagnosis And Treatment Of Torsion Of The Spermatic Cord In The Pediatric Patient

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. Epidemiology
  6. Developmental Anatomy
  7. Etiology
  8. Presentation
  9. Differential Diagnosis
  10. Prehospital Care
  11. Emergency Department Evaluation
    1. History
    2. Physical Examination
  12. Laboratory Studies
  13. Imaging Studies
  14. Treatment
    1. Surgical Management
    2. Nonsurgical Management
      1. Detorsion Procedure
      2. Pharmaceutical Treatment
  15. Outcomes
  16. Medicolegal Concerns
  17. Summary
  18. Risk Management Pitfalls In The Emergency Treatment Of Torsion Of The Spermatic Cord
  19. Case Conclusion
  20. Clinical Pathway: Treatment Of The Acute Scrotum
  21. Tables and Figures
    1. Table 1. Differential Diagnosis of Testicular Torsion
    2. Figure 1. Bell Clapper Deformity
    3. Figure 2. The Acute Scrotum In Children
    4. Figure 3. Acute Torsion (High-riding, Horizontal Lie)
    5. Figure 4. Acute Scrotal Hematocele
    6. Figure 5. Infarcted Testis
    7. Figure 6. Results Of Seminal Analysis After Unilateral Orchidopexy For Torsion
    8. Figure 7. Testicular Survival From Onset of Pain To Surgery
  22. References


The incidence of acute torsion of the spermatic cord (TOSC) has been estimated to be 4.5 cases per 100,000 population.1 Others have cited an annual incidence of 1 in 4000 males under 25.2 While not especially common in the emergency department (ED), these cases are important to the patient, the clinician, and the consultants who might be needed. Sorting out the etiology can be vexing. Doing so frequently involves not only examination but also imaging and consultation with surgery or urology colleagues. When faced with an acutely swollen and painful scrotum, the surgeon must decide quickly whether or not to explore the scrotum, and if a testicular torsion is found, choose between testicular salvage and removal. Both decisions can have consequences for the patient. The outcome for the patient is as dependent on the time elapsed from the onset of the attack, as it is on the decisions of the surgeon.

Case Presentations

A 14-year-old, previously healthy male presents to the ED on a typically busy Friday evening complaining of scrotal pain that started 2 days ago. His mom is visibly upset and states that the patient was taken to his primary pediatrician 2 days ago for a separate complaint, but he denied having pain despite being asked if anything else was bothering him. When questioned, the patient states he did have scrotal pain at that time, but he was too embarrassed to say anything. Further history reveals that the pain was acute in onset, sharp, left-sided, and has progressively gotten worse. He denies dysuria or other urinary complaints, and there have been no fever or chills. The patient denies suffering any trauma. He admits to nausea but has not vomited. The remainder of the review of systems is negative. The physical examination is remarkable for a tender, swollen left hemiscrotum. The left testis is high-riding compared to the right, and the patient fails to display a cremasteric reflex on the affected side. The right testis is nontender, and the remainder of the examination is noncontributory. You inform the patient’s mom of the likely diagnosis and of your plan to obtain an ultrasound and consult urology. As you walk down the hall, your mind is racing. Is this testicular torsion? What else could it be? How will you determine the diagnosis definitively? Is there something you should be doing right now? You have heard some people say that an attempt to manually detorse is indicated. Is that true? Can it make matters worse? If you do decide to do it, which way should you try to flip the testis? Will ultrasound guidance help you choose the best direction? You also realize the clock is ticking. How long has the problem been going on? When will the function of the organ become irreparably damaged? Is there a time limit on how long the testis itself can survive a torsion of its blood supply? What diagnostic studies should you order? Should you notify the urology 2011service now or wait till you know the diagnosis? Are there any pharmaceuticals you should administer to minimize the injury? If this teen had spoken up sooner, would the outcome have been affected? What should you do first?


Acute scrotal emergencies are not the most frequent crisis faced in an emergency department (ED). It is said that an acute scrotum occurs with 1/20th of the frequency of an acute abdomen.3 Cincinnati Children’s Hospital found that in a 2 year period, there were 238 acute scrotal emergencies which represented only 0.13 % of their ED patients.4 The incidence of acute TOSC has been estimated to be 4.5 cases per 100,000 population.1 Others have cited an annual incidence of 1:4000 males under 25, with torsion presenting most often during 2 time periods of a males life. The first peak in incidence involves those under a year of age, and the second peak occurs around age 13.2,5 These cases are important to the patient, the clinician, and the consultants who might be needed. Sorting out the etiology can be vexing. Doing so frequently involves not only examination but also imaging and consultation with surgery or urology colleagues. When faced with an acutely swollen and painful scrotum, the surgeon must decide quickly whether or not to explore the scrotum. If a testicular torsion is found, the surgeon must choose between testicular salvage and removal. Both decisions can have consequences for the patient.

This month’s issue of Pediatric Emergency Medicine Practice will delve into the problem of the male with a possible TOSC. The authors examine existing literature to develop a strong strategy for clinicians that explains what to do and when to do it in the diagnosis and treatment of TOSC.

Critical Appraisal Of The Literature

Ovid MEDLINE® and PubMed were searched for literature published in core English-language clinical journals from 1970-2010 on the subject of human subjects aged 1 month to 18 years with TOSC. Search terms included torsion, testicular cord, and spermatic cord. Results containing patients with neonatal testicular torsion were excluded. This search resulted in 640 articles. Modifiers were added in order to filter the search. “Diagnosis” resulted in 160 articles, “treatment” in 119, “incidence” in 56, “ultrasound” in 65, “risk factors” in 19, and “outcomes” in 14. These lists were reviewed for appropriate articles as were the reference pages of thorough review articles and other papers related to testicular torsion.

Risk Management Pitfalls In The Emergency Treatment Of Torsion Of The Spermatic Cord

  1. “I didn’t think I needed to perform a genital examination in a crying infant.” Remember that the incidence of torsion is high in the first year of life, decreasing in incidence until the pubertal years, 14 and up.
  2. “I didn’t consider acute torsion in my patient with abdominal pain.” Risk factors for TOSC include recent trauma, sexual activity, exposure to cold, cryptorchidism, recurrent episodes of testicular or scrotal pain, abdominal pain, nausea, and/or vomiting.
  3. “My patient has abdominal pain and vomiting, but he has a normal appearing scrotum, so it can’t be torsion of a cryptorchid testis.” Though the absence of rugae usually indicates cryptorchid testis, cases do exist where the patient’s testes appeared normal.
  4. “I performed manual detorsion, and my patient immediately felt relief. The procedure was 100% successful.” Even with ultrasound guidance and palpable relief of torsion, some twist may persist. Even if the twist is 100% relieved, the chance that the patient will have a bell clapper deformity of the involved testis is high, not to mention the chance that the contralateral testis is also abnormally secured in its hemiscrotum.
  5. “I untwisted a torsed spermatic cord after giving my patient an inguinal block with lidocaine. I thought that the pain relief signaled a successful procedure.” Since the nerve is blocked, pain cannot be used as a guide to the success or failure of the procedure.
  6. “My patient has complained of pain before, but it was awhile ago and it doesn’t happen regularly.” Failure to recognize recurrent episodes of pain may herald torsion. Many patients have a history of similar pain that remits spontaneously before actually presenting with a twist requiring surgery. These patients may benefit from an orchiopexy even if they haven’t had unremittant torsion.
  7. “My patient’s testis was pink and vibrant in the scrotum after torsion, so the testis was left intact.” Studies have demonstrated adverse effects on the contralateral testis presumably from antibodies against normal testicular cells formed after an ischemic event.
  8. “This patient had no cremaster reflex, so I ruled out torsion of the spermatic cord.” While the presence of a cremaster reflex was 100% sensitive in one study, the sample size may not have been large enough to generalize these findings to all cases with all examiners.21 The wiser choice is to back up your diagnosis with an imaging study like color Doppler sonography of the scrotum.
  9. “I never realized that pyuria does not rule out torsion.” Yes, pyuria is found most often in patients with acute epididymitis; some patients with torsion may have pyuria.
  10. “I relied on Prehn sign to rule out torsion and rule in epididymitis.” Prehn sign (relief of scrotal pain with elevation of the sac) is only 45% sensitive, meaning it can’t rule out torsion in over half of the cases.

Tables and Figures

Table 1. Differential Diagnosis of Testicular Torsion


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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  2. Anderson JB, Williamson RC. Testicular Torsion in Bristol: A 25 Year Review. Br J Surg. 1998; 75:988-992. (Retrospective; 670 patients)
  3. * Knight PJ, Vassey L. The Diagnosis and Treatment of the Acute Scrotum in Children and Adolescents. Ann Surg. 1984;200(5):664-673. (Retrospective; 395 patients)
  4. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg. 1995;30(2):277-281. (Retrospective; 238 patients)
  5. Melekos MD, Asbacch HW, Markou SA. Etiology of Acute Scrotum in 100 Boys with Regard to Age Distribution. J Urol. 1987;139:1023-1025. (Retrospective; 100 patients)
  6. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. 1976;63:465-476. (Retrospective; 353 patients)
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  9. The Testicles. In: Standing S, ed. Gray’s Anatomy, The Anatomical Basis of Clinical Practice, 29th ed. Edinburgh: Elsevier;2005:1305-1313. (Textbook)
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Martin I. Herman; Jonathan Jacobs

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October 1, 2011

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