A patient presents with right-sided testicular pain and swelling for 1 hour, associated with nausea and vomiting. Physical examination shows tenderness and swelling in both the epididymis and testicle itself. The epididymis is anterior to the testicle, and palpation of the spermatic cord reveals a 1cm nodule about 2 cm above the testicle.
You call the urologist because the patient has spermatic cord torsion. While waiting you apply color Doppler ultrasound which confirms no flow. You try to untwist the testicle laterally but there is resistance and increase of pain. Should you wait for the urologist? Is there anything else you can do?
The idea that all torsion is medial, treated by “opening the book,” has been demonstrated to be false in every generation, yet the over-simplified teaching persists. Thanks to Sessions’ 2003 excellent article showing 1/3 incidence of lateral torsion, awareness is improving.
You go the opposite direction, detorsing medially. The patient experiences relief. Color Doppler ultrasound now shows arterial flow. Torsion can be up to 3 full turns so the patient still needs to go to the operating room. But you have restored arterial flow and improved the patient’s chance of testicular salvage.
Endpoints of manual reduction:
-lack of resistance to the reduction
-relief of pain
-resolution of abnormal lie
-testicle drops lower in the scrotum to a normal position
-may feel a “snap” into place (Hinman’s Atlas of Pediatric Urologic Surgery)
-untwisting of spermatic cord knot
-return of color ultrasound flow
Take Home Points:
-Torsion can occur in either direction, so use resistance and relief as your first endpoints
-Palpate the spermatic cord knot and note the lie and length as additional endpoints
-Use color Doppler ultrasound as the ultimate endpoint