Management

As previously discussed, if testicular torsion is suspected, the testicle must be explored to confirm or refute the diagnosis.

Testicular Torsion

Treatment for suspected testicular torsion is immediate surgical exploration with intraoperative detorsion and fixation of the testes. Studies have found that testicular tissue becomes increasingly unsalvageable from 4-6 hours. Reported testicular salvage rates are 90% to 100% if surgical exploration is performed within six hours of symptom onset, decrease to 50% if symptoms are present for more than 12 hours, and are typically less than 10% if symptom duration is 24 hours or more(16). Even if the diagnosis has been delayed the scrotum should still be explored. If the testis is ischaemic and unsalvageable an orchidectomy may be indicated to prevent formation of anti-sperm antibodies leading to infertility. Patients should ideally have pre-operative counselling regarding this.
Whilst awaiting surgery it is important to manage symptoms with analgesia and antiemetics. Manual detorsion may also be attempted as an adjunct to surgery. This is typically done by rotating the testicle from medial to lateral (clockwise) and usually require at least 360 degrees. This is only a temporary measure whilst awaiting surgery and requires strong analgesia +/- sedation +/- nerve blocks (16).

Torsion of the appendages

Torsion of the appendages cause no damage to the testis and can be managed conservatively with NSAIDs, ice and support. Pain typically lasts a week and is self-limiting. It is important to reassure parents. This is clearly a diagnosis of exclusion.