Approach

In acute testicular torsion, timely surgical exploration is needed to preserve testicular function. Patients presenting with a symptom duration of <4 to 6 hours have a greater likelihood of testicular viability. Testicular salvage rates decline as the duration of symptoms increases, with greatly reduced testicular salvage at 24 hours and consistently poor results beyond 48 hours.[19]​[22] If presentation is significantly delayed, or diagnosis is unclear, diagnostic testing can be used to rule out other causes of an acute scrotum that can be managed conservatively.[19]

Surgical management in non-neonates

In the setting of acute testicular torsion, immediate surgical consultation for exploration with possible detorsion is essential to optimize testicular salvageability.[11][23]​​​ 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.[39] 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.[40]

Some studies have tried to identify predictors of testicular viability to determine which patients need orchiectomy versus orchidopexy. One study found that their studied parameters (symptom duration, color Doppler results, and presence of intraoperative bleeding) were not predictive separately, but when taken together, and showing consistent result agreement, helped to identify the appropriate treatment choice.[41] Another study found that heterogeneous testicular parenchyma on ultrasound was a reliable indicator of testicular nonsalvageability. All 37 patients in this study with heterogeneity on sonogram had nonviable testicles at exploration. Homogeneous testicular parenchyma on sonogram may signify a greater likelihood of testicular viability and necessitate immediate surgical exploration.[42]

Surgical management in neonates

Born with torsion

  • Management of extravaginal torsion that occurs during testicular descent is controversial.[19] Some urologists advocate no surgical intervention, 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.[19][43]​​[44] Most urologists agree that a neonate born with unilateral torsion can be stabilized and explored on a semi-elective basis to optimize anesthetic risk.[45] A meta-analysis of 196 patients across 9 publications found urgent bilateral exploration had a salvage rate of 7% for the affected testis and prevented asynchronous torsion in 4% of cases. The authors concluded that 8% to 12% of neonates would benefit from bilateral exploration at the time of diagnosis.[46]

Born with normal testes and develop subsequent torsion

  • Neonates who have normal testes documented at birth who subsequently are noted to have an acute scrotum (signs and a physical exam consistent with torsion) require emergent exploration.[19]

Manual detorsion

Manual detorsion may be attempted if surgery is not available within 6 hours or while preparations for surgery are being made.[3][34]​​​ Manual detorsion is a temporizing measure. The technique involves rotating the right testicle counterclockwise and the left testicle clockwise. In other words, the affected testicle is rotated as if opening a book, hence the "open book" method. Adequate sedation and pain control should be provided. Blood flow on Doppler is the objective measure of successful detorsion.[3] Clinical relief or improvement after manual detorsion is highly suggestive of the diagnosis of testicular torsion. 

Supportive care

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

Prosthetic device

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 perhaps the patient's psychological well-being. 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.[47][48]

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