Pediatric Urology

Atypical Presentation of Testicular Torsion: Time is of the Essence

    Christina P. Carpenter, MD, MS, Interim Chief of Pediatric Urology at NewYork-Presbyterian/ Columbia and NewYork-Presbyterian Morgan Stanley Children’s Hospital, is working to ensure that pediatric testicular torsion is diagnosed and treated rapidly when a child presents with symptoms in the emergency department.

    “Pediatric acute testicular torsion (ATT) is a genitourinary emergency, and therefore any time a young boy or adolescent has testicular pain, torsion should be considered in the diagnosis,” she says. “However, torsion can present with atypical symptoms that obscure the diagnosis, resulting in a delay in care. There has been a major effort in our hospital to track each torsion event from the time the patient arrives in the ED to the time that the diagnosis is made to the time they go to the operating room for treatment. While our center currently meets national time standards, we continue to seek areas of improvement that will result in even more rapid treatment of acute testicular torsion.”

    There has been a major effort in our hospital to track each torsion event from the time the patient arrives in the ED to the time that the diagnosis is made to the time they go to the operating room for treatment. While our center currently meets national time standards, we continue to see areas of improvement that will result in even more rapid treatment of acute testicular torsion.

    — Dr. Christina Carpenter

    Testicular torsion results in obstruction of blood flow, which can lead to the potential loss of the testicle. Therefore, minimizing the time interval from determining the diagnosis to surgical intervention is critical. “The reason for surgical urgency is to salvage the testicle,” emphasizes Dr. Carpenter. “We consider six hours as a rough guideline for the maximum timeframe when you might expect testicular loss. As with any organ in the body, a testicle, if deprived of blood flow for too long, is unlikely to reperfuse. We use six hours as our cap, but there’s no magic number. I have seen testicles that have gone without blood flow for much longer than six hours that were able to be saved as well as those without blood flow for less than six hours that did not reperfuse once they were untwisted and could not be salvaged. It’s not a perfect science.”

    Dr. Carpenter notes that intermittent torsion can also occur in which the testicle twists and then resolves. “This is not necessarily an emergency, but you don’t know if the problem will recur,” she says. “We would therefore have a discussion with the family about whether to perform surgery to prevent a potential recurrence. Importantly, the family should be told that that if the testicular pain returns, they should immediately return with their child to the ED.”

    Improving Timeliness of Care

    Dr. Carpenter and her colleagues in the Department of Urology at NewYork-Presbyterian/ Columbia recently conducted a study to identify factors that contribute to a delay in treatment of ATT and to determine how treatment might be expedited.

     In their study, the physicians analyzed retrospective data on 111 patients, 18 years and younger, who had surgery for a diagnosis of ATT between April 4, 2005, and August 21, 2021. A Doppler scrotal ultrasound was obtained in 107 of the patients, with 101 of those patients diagnosed with testicular torsion. In the four patients who did not have an ultrasound, physical examination indicated the need for surgery. The research team also analyzed median time from symptom onset to surgery in 84 patients (3.5 hours) and from ED triage to surgery in 64 patients (3.2 hours) as related to risk of testicular loss. Their findings, which were published in the May 18, 2023, online issue of Pediatric Emergency Care, showed:

    • 41% of all patients reported atypical symptoms or clinical history
    • In 26% of patients, abdominal pain was the most frequently reported atypical symptom
    • 90% of patients were found to have acute testicular torsion on intraoperative evaluation; 9% had a non-torsed testicle with an appearance of recent ATT; 1 patient had an isolated torsed appendix testis
    • 35% of patients underwent an orchiectomy due to testicular necrosis consistent with history of torsion
    • Symptom duration and patient age were significant predictors of testicular loss; older age was associated with greater likelihood of testicular salvage
    • Median duration of symptoms before ED presentation was 9 hours in all patients, 5 hours in those patients whose testicles were salvaged, and 40 hours in those requiring orchiectomy

    Patients presenting to the ED with acute testicular torsion reporting atypical symptoms or history experience slower transit from arrival in the ED to operative management and may be at greater risk of testicular loss. Increased awareness of atypical presentations of pediatric acute testicular torsion may improve time to treatment.

    — Study Authors, Atypical Presentation Delays Treatment of Pediatric Testicular Torsion, Pediatric Emergency Care

    Practicing in a major metropolitan academic medical center, Dr. Carpenter can see as many as three torsions per week, but the condition is considered rare. “Torsion can affect any male, but more commonly presents in teenagers,” she says. “It’s not as common in adults but does occur so you can’t rule out the diagnosis based on age alone. While the cause of testicular torsion remains unknown, it is thought that puberty and hormonal changes may play a role given that the condition is more prevalent in adolescents. There is also a belief that anatomical variants may be a predisposing factor. However, these deviations are undetectable until you are in surgery and able to directly examine the testicle.” 

    Dr. Carpenter notes that if a testicular exam is consistent with or suggestive of torsion, that this is reason enough to bring a patient to the operating room. “While an ultrasound certainly will give us a definitive yes or no, it is more important to operate as soon as possible because we don’t want to delay any care that we might deem clinically necessary,” she explains. “When a patient comes into our ED with symptoms indicative of torsion, we usually obtain a scrotal ultrasound to support that diagnosis, particularly if the patient presents with non-traditional symptoms such as abdominal pain, nausea, or vomiting. Generally, however, a good physical exam on a patient who has torsion will give you the diagnosis. Their testicle may be firmer and might be abnormally positioned. Discoloration of the scrotum indicates the torsion has been present for a longer period of time.” 

    She also points out that another factor influencing time to diagnosis could be communication with the patient. “Children and teens may be embarrassed to say that they’re having genital pain, so instead describe very vague symptoms such as their stomach hurts. Some patients may be nonverbal or have difficulty communicating,” notes Dr. Carpenter. “It is incumbent upon us to do the best we can to communicate at the patient’s level, asking them to localize the pain or try to discuss their symptoms. Are they limping when they walk because they’re in so much pain? Is there any nausea or vomiting, which can accompany testicular torsion?” 

    The surgical procedure for ATT is performed through a single incision at the midline of the scrotum. “If the testicle has died, unfortunately we have to remove it,” says Dr. Carpenter. “If the testicle is still viable, we untwist it, allow the blood flow to return. While waiting to see if reperfusion is successful, we also address the other testicle during the procedure. If twisting occurred on one side, it could potentially occur on the other side. Once we address the contralateral side, we go back to the testis that was twisted to determine if it reperfused. If so, then we sew it in place such that it can’t twist in the future. If blood flow hasn’t returned and the testis still appears nonviable, then we go ahead and remove it. The procedure usually takes less than 45 minutes.”

    Promoting Awareness of Acute Testicular Torsion

    The experience of Dr. Carpenter and her colleagues at NewYork-Presbyterian/Columbia and studies from other centers underline the significance of minimizing the time from symptom onset of acute testicular torsion to treatment for saving the testicle. They advocate that, “For providers, this means that treatment-related parameters including time to initial clinical evaluation in the ED, imaging and diagnosis, and start of surgery all represent modifiable targets with promise to improve rates of testicular salvage.” 

    Importantly, Dr. Carpenter stresses the need for awareness among emergency medicine physicians and other pediatric specialists who may be the first line of care for patients with testicular torsion. “Our goal with this study is to help bring awareness of the nontraditional presentations of torsion and to maintain a high level of suspicion so that we can treat these patients quickly and successfully.”

      Learn More

      Moran GW, Wang C, Chung R, Miyad Movassaghi, Carpenter CP, Finkelstein JB. Atypical Presentation Delays Treatment of Pediatric Testicular Torsion. Pediatric Emergency Care. 2023;Publish Ahead of Print. doi:10.1097/pec.0000000000002969

      For more information

      Dr. Christina Carpenter
      Dr. Christina Carpenter
      [email protected]