Torsion of the testicle

I am familiar with this condition by virtue of personal experience and by virtue of working at a small hospital, where practically all the studies are emergency examinations.

This is a devastating disease, which if not diagnosed promptly, will lead to loss of testicle. The condition is most common in young adolescent boys. The typical history is that of acute onset of severe unilateral scrotal pain, sometimes with swelling. The etiology of this condition is twisting of the testicle on its pedicle, resulting in vascular compromise.

It is stated that once the vascular compromise begins, irreversible changes in the testicle occur in 6 to 12 hours. Watching and waiting is not an option. The urology literature suggest that if there is strong clinical indication of testicular torsion, surgical exploration is the proper method to both treat and to exclude the diagnosis.

However, in this age of high-technology, there are a host of studies that can be utilized to either make or to exclude the diagnosis of testicular torsion. The main differential consideration is epididymitis, an inflammatory condition. In testicular torsion, there is diminished blood flow to the testicle. In epididymitis, there is normal blood flow to the testicle and increased blood flow to the epididymis, a small structure which is situated superior and medial to the testicle. There are other conditions such as trauma, neoplasm, varicocele, hydrocele, spermatocele, and torsion of the appendix testis which also need to be considered when a patient presents with a mass or pain in the scrotum.

The traditional test utilized to differentiate testicular torsion from epididymitis is a nuclear testicular scan. Radioactive material is injected and images of the material are taken to demonstrate flow and vascularity. The results of this study should be available within 30 minutes, a reasonable period of time. The differentiation of testicular torsion is easily made on the basis of diminished flow to the side of the pain, corresponding to the location of the testicle. In epididymitis, increased flow will be seen on the side of the pain. Therefore it is critical to correlate the result of this test with the location of the patients pain. Sometimes pictures are taken with markers, to indicate the exact site of pain.

More recently, ultrasound examinations with utilization of color Doppler have been used to differentiate various scrotal conditions. The problem with ultrasound is that it is highly dependent on the operator, which is typically a nonphysician who generates pictures which are then interpreted by a physician. In addition, younger boys sometimes have flow patterns which are difficult to identify. The literature suggests a < 5 percent false negative rate in differentiating testicular torsion from other conditions.

Color doppler image of testicle with flow.

The standard of care regarding the diagnosis and treatment of this condition allows very little reason on the part of medical practitioners and hospitals to fail and allow for testicular loss. Almost all hospitals now have ultrasound and nuclear medicine availability. Some smaller hospitals have tried to limit access to this technology during regular daytime hours. However, those of us who deal with emergencies on a regular basis know that emergency conditions do not limit themselves to convenient hours. By law, emergency rooms must provide the same level of care during the middle of the night as they do during the middle of the day. This pertains both to the availability a physician specialties and diagnostic technology.

In summary, the standard of care for diagnosis and treatment of testicular torsion is high. The failure to order tests to exclude the diagnosis and the failure to operate within a timely period can result in testicular loss. Despite the fact that testicular loss generally does not affect fertility, case law, at least in Florida, attaches are very high value to this loss. This in part is due to the emotional appeal which is made to juries, regarding the future sufferings related to testicular loss, which is the basis for determining damage.