Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

non-neonate

1st line – immediate urological consultation for emergency scrotal exploration

Back
ACUTE
|
non-neonate
|
with high suspicion of torsion
1st line – 

immediate urological consultation for emergency scrotal exploration

In the setting of acute testicular torsion, immediate surgical consultation for exploration with possible de-torsion is essential to optimise testicular salvageability.[12][24]​​​ The decision for orchiectomy versus orchidopexy is based on the extent of damage to testicular tissue. Testicular function is often compromised in patients with testicular torsion. However, testicular torsion can be partial with some continuation of blood flow maintained; therefore, exploration may still be attempted after delayed diagnosis.[40] During exploration, the contralateral testis is fixed to the posterior wall to prevent future bilateral testicular torsion. Several operative techniques have been described on the fixation of the testis with very limited evidence supporting one technique over another with regards to preventing a recurrence.[41]

Plus – supportive care

Back
ACUTE
|
non-neonate
|
with high suspicion of torsion
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with testicular torsion experience severe pain. Adequate pain relief and sedation (e.g., using morphine sulfate) should be provided, especially when performing ultrasound and manual de-torsion. Some patients also experience nausea and vomiting; antiemetics (e.g., ondansetron) can be given to help prevent these symptoms.

Primary options

morphine sulfate: children: 0.1 mg/kg subcutaneously/intravenously every 4 hours when required, maximum 10 mg/dose; adults: 10 mg intramuscularly/intravenously every 4 hours when required

and

ondansetron: children 1 month to 12 years of age and ≤40 kg: 0.1 mg/kg intravenously as a single dose; children >12 years of age or >40 kg: 4 mg intravenously as a single dose; adults: 4 mg intramuscularly/intravenously as a single dose

Consider – prosthetic device

Back
ACUTE
|
non-neonate
|
with high suspicion of torsion
Consider – 

prosthetic device

Additional treatment recommended for SOME patients in selected patient group

The traumatic experience of losing a testicle can be mitigated by offering a prosthetic device, usually a saline-filled silicone implant, which can improve cosmetic appearance and help psychologically. However, if the testis has been removed through a scrotal incision, a prosthesis should not be placed at that time but rather at a later date, after the wound has healed. A prosthesis that is placed through a scrotal incision carries a high risk of being extruded. While studies have demonstrated low extrusion rates with immediate prosthesis placement via a scrotal incision using an intravaginal technique, this remains controversial.[48][49]

2nd line – manual de-torsion followed by scrotal exploration

Back
ACUTE
|
non-neonate
|
with high suspicion of torsion
2nd line – 

manual de-torsion followed by scrotal exploration

Manual de-torsion may be attempted if surgery is not available within 6 hours or while preparations for surgery are being made.[3][35]​​

Manual de-torsion is a temporising measure. The technique involves rotating the right testicle counter-clockwise and the left testicle clockwise. In other words, the affected testicle is rotated as if opening a book, hence the 'open book' method.

Plus – supportive care

Back
ACUTE
|
non-neonate
|
with high suspicion of torsion
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with testicular torsion experience severe pain. Adequate pain relief and sedation (e.g., using morphine sulfate) should be provided, especially when performing ultrasound and manual de-torsion. Some patients also experience nausea and vomiting; antiemetics (e.g., ondansetron) can be given to help prevent these symptoms.

Primary options

morphine sulfate: children: 0.1 mg/kg subcutaneously/intravenously every 4 hours when required, maximum 10 mg/dose; adults: 10 mg intramuscularly/intravenously every 4 hours when required

and

ondansetron: children 1 month to 12 years of age and ≤40 kg: 0.1 mg/kg intravenously as a single dose; children >12 years of age or >40 kg: 4 mg intravenously as a single dose; adults: 4 mg intramuscularly/intravenously as a single dose

neonate

1st line – initial stabilisation + urological consultation ± semi-elective scrotal exploration

Back
ACUTE
|
neonate
|
with torsion at birth
1st line – 

initial stabilisation + urological consultation ± semi-elective scrotal exploration

Management of extra-vaginal torsion that occurs during testicular descent is controversial.

Some urologists advocate no surgical intervention as there is a reduced potential for salvage of the testicle, whereas others recommend surgical exploration, with excision of the necrotic testis and contralateral fixation to prevent future contralateral torsion and lifelong complications with respect to fertility and hormone production.[20][44]​​[45]

Most urologists agree that a neonate born with unilateral torsion can be stabilised and explored on a semi-elective basis to optimise anaesthetic risk.[46]

Plus – supportive care

Back
ACUTE
|
neonate
|
with torsion at birth
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with testicular torsion have severe pain. Adequate pain relief and sedation should be provided, especially when performing ultrasound and manual de-torsion. Some patients also experience nausea and vomiting; anti-emetics can be given to prevent these symptoms.

Primary options

morphine sulfate: 0.05 to 0.2 mg/kg subcutaneously/intramuscularly/intravenously every 4 hours when required

and

ondansetron: consult specialist for guidance on dose

1st line – immediate urological consultation for emergency scrotal exploration

Back
ACUTE
|
neonate
|
with normal testes at birth and subsequent torsion
1st line – 

immediate urological consultation for emergency scrotal exploration

Neonates born with normal testicles documented at birth who then develop an acute scrotum (signs and a physical examination consistent with torsion) require emergency scrotal exploration.[20]

Plus – supportive care

Back
ACUTE
|
neonate
|
with normal testes at birth and subsequent torsion
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with testicular torsion experience severe pain. Adequate pain relief and sedation should be provided, especially when performing ultrasound and manual de-torsion. Some patients also experience nausea and vomiting; anti-emetics can be given to prevent these symptoms.

Primary options

morphine sulfate: 0.05 to 0.2 mg/kg subcutaneously/intramuscularly/intravenously every 4 hours when required

and

ondansetron: consult specialist for guidance on dose

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer