Testicular Torsion Emergency Management (EAU 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Testicular Torsion

   Acute onset scrotal/testicular pain, often with nausea/vomiting

   1. ●

      Action

      Rapid Clinical Assessment

      Document symptom onset time - critical for prognosis

      • Symptom onset time (critical!)
      • High-riding testis with transverse lie
      • Absent cremasteric reflex (sensitive)
      • Tender, swollen hemiscrotum
      • Nausea/vomiting common
      • May have lower abdominal pain
      1. ◆

         Decision

         Clinical Suspicion High?

         Classic presentation: acute pain + high-riding testis + absent cremasteric reflex

         1. ●

            Action

            Immediate Urology Consult

            Do NOT delay for imaging if clinical suspicion high

            • Call urology STAT
            • Prepare for OR
            • NPO status
            • IV access
            • Consent for exploration ± orchiectomy
            1. ●

               Action

               Attempt Manual Detorsion

               If urology/OR not immediately available

               • Rotate testis medial to lateral ('open book')
               • Turn 180° at a time, reassess
               • May require 1-3 full rotations
               • Success = pain relief + testis descent
               • If pain increases, try opposite direction
               • Does NOT replace surgical exploration
               1. ⚠

                  Warning

                  ⚠️ TIME-CRITICAL EMERGENCY

                  Salvage rates by time from symptom onset (EAU 2024)

                  • <6 hours: 90-100% salvage rate
                  • 6-12 hours: ~50% salvage rate
                  • 12-24 hours: ~10% salvage rate
                  • >24 hours: Near 0% salvage
                  • Target: Immediate surgery (EAU Strong Recommendation)
                  1. ●

                     Action

                     Surgical Exploration

                     Definitive management - do not delay

                     • Scrotal incision and delivery of testis
                     • Detorsion and assessment of viability
                     • Warm saline wrapping
                     • If viable → orchiopexy
                     • If non-viable → orchiectomy
                     • Contralateral orchiopexy (bilateral bell-clapper)
                     1. ◆

                        Decision

                        Testis Viable?

                        Assess color, bleeding, Doppler after detorsion

                        1. ●

                           Action

                           Bilateral Orchiopexy

                           Fix both testes to prevent recurrence

                           • 3-point fixation with non-absorbable suture
                           • Fix contralateral testis (bilateral bell-clapper)
                           • Place in dartos pouch
                           1. ✓

                              Outcome

                              Testis Salvaged

                              Follow-up: monitor for atrophy, fertility counseling

                        2. ●

                           Action

                           Orchiectomy + Contralateral Orchiopexy

                           Non-viable testis removal

                           • Remove necrotic testis
                           • Fix contralateral testis
                           • Discuss future prosthesis option
                           • Counsel re: fertility (usually preserved)
                           1. ✓

                              Outcome

                              Testis Lost

                              Counsel patient: single testis adequate for fertility/hormones

         2. ●

            Action

            Doppler Ultrasound

            Only if diagnosis uncertain - do NOT delay surgery

            • Absent/decreased blood flow suggests torsion
            • Whirlpool sign (twisted cord)
            • Sensitivity 82-100%, Specificity 97-100%
            • Normal flow does not rule out intermittent torsion
            • If positive or equivocal → surgical exploration
            1. ●

               Action

               Consider Alternative Diagnoses

               If ultrasound shows normal flow

               • Torsion of appendix testis/epididymis
               • Epididymitis/orchitis
               • Incarcerated inguinal hernia
               • Trauma/hematocele
               • Idiopathic scrotal edema