Case vignette
14yo M p/w 23hrs R testicular pain, starting after a somersault.
Uncomfortable appearing male with VS WNL. His R testis is firm, tender, with absent cremasteric reflex. His TWIST score is 5.
What do you see?
GU1 US1: edematous/heterogeneous appearance of testicle/epididymis. Additionally, anechoic (black) fluid surrounding testicle, concerning for edema vs hydrocele.
GU1 US2: on color power doppler, poor to no blood flow in abnormal testes
GU1 US3: using same settings, clear blood flow in unaffected testes (always compare sides!)
What do you do next?
You place an emergent call to Urology. They are 1.5hrs away and unsure if they should come in due to duration of pain. You discuss the possibility of torsion/detorsion and that tissue may still be salvageable. They agree to come in STAT.
What do you do next?
While waiting, you attempt manual reduction. You perform the 'open the book' technique; pain does not worsen, but it also does not improve. The patient is ultimately taken to the OR, where torsion is identified and the testicle remains viable.
Teaching points. Even if pain has been present for days, advocate for emergent Urology evaluation if you suspect torsion! Testicles can torse and detorse, and there are case reports of tissue being viable multiple days out from pain onset. (If you have to wake the US tech up to solidify your case, do it.)
US can show absent arterial blood flow, confirming your suspicion. If you see this, consider manual detorsion while awaiting Urology. However, US findings vary greatly. Testicles can be detorsed at time of US, leading to false negatives. Inflammation can suggest alternative (and incorrect) diagnoses, like epidymyitis. Arterial blood flow can be intact (or have increased resistance), while venous blood flow can be absent. Tissue death/inflammation can lead to heterogeneity, with necrosis and hemorrhage. (A good mantra in EM: always compare sides!) The point: maintain high suspicion and consult urology for a concerning history/exam and any ultrasound abnormalities. Document your timing.
P.S. The 'open the book' technique recommends 540 degrees plus of rotation. This requires analgesia and can be difficult to perform. In addition, if pain worsens, the testicle may be torsed the opposite direction (potentially ~1/3 of cases). Even if you are able to detorse, surgical exploration is necessary, during which bilateral orchiopexy may be performed.
Sources: https://pubmed.ncbi.nlm.nih.gov/12544339/; great review of testicular torsion US: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5895684/
Residents/staff: Dr. Sean Hickey, Dr. Daniela Chan, Dr. Beech Burns
Testicular Torsion