Two young men presented to the emergency department with testicular torsion, and both underwent manual detorsion after the diagnosis was made with bedside ultrasound. Restored blood flow was documented, also with bedside ultrasound. Both patients were later able to undergo successful orchidopexy for definitive treatment. (J Emerg Med. 2019 Oct 22. doi: 10.1016/j.jemermed.2019.09.020. [Epub ahead of print].)
This article reminded me of a case from several years ago. A patient presented with scrotal pain concerning for torsion, and ultrasound confirmed the diagnosis. No urologist was available, however, at that hospital, so the physician sought a transfer. I immediately accepted the request, but suggested an attempt at manual detorsion before transfer because a significant amount of time had passed since the first symptoms appeared. The treating physician said he would attempt it.
When the patient arrived, we were initially relieved to see that he was pain-free and assumed that the detorsion had been successful. Unfortunately, when the patient was taken to the OR, an ischemic testicle was found. After detorsion, the ischemia was found to be irreversible and the testicle was lost.
Perhaps this was unavoidable because so much time had passed between onset of symptoms and urology evaluation. Manual detorsion is also painful and often not well tolerated by patients unless adequate pain control is achieved. Without a urologist immediately available, it is our best strategy to save the ischemic testicle. The ability to document our detorsion success may give us the confidence to transfer our patient or to await specialty consultation.
Testicular ultrasound can seem intimidating, but it shouldn't be. It is a straightforward exam, with the goal solely to document the presence or absence of flow. Establishing a diagnosis of torsion is not always easy, but documenting flow after an attempt at detorsion is simple. A high-frequency transducer should be used, with the color flow option selected. Most machines have the option to select the sensitivity of the Doppler, and a low-flow state should be selected. Power Doppler can also be used if available because it is more sensitive to low-flow states. Once the box is in place over the testicle, flow should be visible within the parenchyma of the testicle, not just around the periphery.
Think about manual detorsion with ultrasound confirmation the next time you encounter testicular torsion. You just might save the testicle.
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Dr. Buttsis the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter@EMNSpeedofSound, and read her past columns athttp://bit.ly/EMN-SpeedofSound.