1 Do infants and toddlers get testicular torsion?

Neonates most frequently have extravaginal torsion (twisting above the tunica vaginalis), which usually occurs in utero and is more often associated with a nonviable testicle despite early discovery. Intravaginal testicular torsion (twisting of the spermatic cord within the tunica vaginalis) is most common in the second decade of life and is rare before the age of 10 years. Nevertheless, boys of any age with acute scrotal pain and swelling require prompt attention, probably radiologic evaluation, and possible surgical evaluation.

Pinto KJ, Noe HN, Jerkins GR: Management of neonatal testicular torsion. J Urol 158:1196–1197, 1997.

Stone KT, Kass EJ, Cacciarelli AA, Gibson DP: Management of suspected antenatal torsion: What is the best strategy? J Urol 153:782–784, 1995.

2 What are some of the important factors in the patient’s history that suggest testicular torsion?

Boys with testicular torsion will frequently report relatively sudden onset of unilateral scrotal pain, and they also may have nausea or vomiting. They may report that they had this pain on prior occasions, but that information does not argue against acute testicular torsion. Fever and painful voiding are uncommon. A history of trauma does not preclude, and can even predispose the patient to, torsion. It is important to recognize that the child with scrotal pathology often reports lower abdominal or groin pain. The patient reporting abdominal pain should always have a genital examination performed. Conversely, it is important to examine the abdomen of all patients with scrotal pain to evaluate peritoneal inflammation, intestinal obstruction, and abdominal masses.

Kamaledeen S, Surana R: Intermittent testicular pain: Fix the testes. BJU Int 91:406–408, 2003.

Lewis AG, Bukowski TP, Jarvis PD, et al: Evaluation of acute scrotum in the emergency department. J Pediatr Surg 30:277–282, 1995.

Seng YJ, Moissinac K: Trauma induced testicular torsion: A reminder for the unwary. Emerg Med J 17:381–382, 2000.

3 What is the “bell clapper deformity”?

Normally, the testicle is fixed to the posterior wall of the scrotum. Although it is almost impossible to detect this on physical examination, the majority of patients with testicular torsion have a congenital condition called the bell clapper deformity, whereby the tunica vaginalis completely envelopes the testicle. This allows the testicle and spermatic cord to twist in relation to the tunica vaginalis, compressing the vessels and nerves within. Although the deformity is bilateral, symptoms usually occur unilaterally. The left testicle is more commonly affected because the left spermatic cord is usually longer than the right.

4 What is manual detorsion?

In general, the prognosis is excellent if the testis is detorsed within 3 hours of symptom onset. Manual detorsion in the emergency setting can allow the testicle to remain viable until emergency surgery can be performed. Although the testicle can twist in either direction, it more commonly twists medially, toward the contralateral thigh. In the manual detorsion procedure, one holds the affected testicle between thumb and forefinger and untwists 360 degrees toward the ipsilateral thigh (Fig. 23-1). If relief is noted, the testicle should be rotated another 360° or more, since the usual twist is 720°. The direction can be reversed if more pain or swelling occurs after the initial maneuver. The trick is not to be shy or reserved while performing this procedure; it will hurt while it is being done, but if done correctly will greatly relieve symptoms almost immediately. Sedation and analgesia may be warranted to facilitate the detorsion procedure. Surgical correction (bilateral orchiopexy) is still necessary after this maneuver; however, the emergency detorsion procedure can help salvage the affected testicle.

Figure 23-1 Technique for manual detorsion of the testicle.

Cattolica EV: Preoperative manual detorsion of the torsed spermatic cord. J Urol 133:803–805, 1985.