Should immediate attempts at manual reduction of a testicular torsion be the standard of care? Without a doubt, timely manual detorsion of a torsed testicle saves the organ from death. (Pediatr Emerg Care. 2019;35:821; Pediatr Emerg Care. 2012;28:80; https://bit.ly/3T9W0N0.)
The detorsion procedure is sometimes quick and easy, but other times it is technically difficult and even unsuccessful. Unfortunately, many physicians are hesitant to attempt manual detorsion because they lack procedural confidence or have anxiety about worsening the torsion.
Testicles torsed for a prolonged period will also have swelling and edema that, along with other mechanical factors, increase the difficulty of these rotation maneuvers. I previously described a maneuver involving downward traction of the torsed testicle that could potentially increase the procedural success rate. (May 2, 2022; https://bit.ly/3pCxaIa.)
I can now report that I have successfully performed the maneuver on several patients and have named it the torsed testicle traction technique. This newly recognized technique was recently published (Pediatr Emerg Care. 2022 Aug 16. doi: 10.1097/PEC.0000000000002827) and is demonstrated with a model in a video in my blog: bit.ly/EMNMellick. The testicular torsion traction technique may be a primary manual reduction maneuver for any testicular torsion, but it may be most useful as an adjunct for failed or difficult reductions.
To perform the testicular torsion traction technique:
- Document with ultrasound the torsed spermatic cord and absence of blood flow to the involved testicle.
- Consider pain control with intranasal fentanyl or intravenous morphine. Medications for pain may be considered optional because the procedure is rapid, and pain relief is an important indicator of success.
- The torsed testicle is grasped with one or both hands, and the spermatic cord is stretched to its maximum length. (Be sure to observe whether the testicle spins or flips during or after the stretching procedure.)
- Perform the manual detorsion procedure of the testicle by externally rotating (right testicle counterclockwise, left testicle clockwise [the open book technique]) until the spermatic cord feels normal. Resistance generally indicates that the reduction maneuver was in the wrong direction.
- Ultrasound of the testicle and the spermatic cord should subsequently confirm return of blood flow and absence of a whirlpool sign or twisting.
The spermatic cord and attached testicle are highly mobile and retractable, and the testicle and spermatic cord under normal conditions can be stretched or protectively retracted by the cremaster muscle in response to cold and flight or fright. (Clin Neurophysiol. 2020;131:1354; StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan; https://bit.ly/3QVTBUg.) Consequently, this stretching maneuver should be physiologically well tolerated.
The twisted spermatic cord becomes edematous, increased in volume, and sometimes incarcerated if the torsion is prolonged. The extraction of a torsed, swollen, incarcerated spermatic cord away from the inguinal canal increases procedural success. Importantly, stretching the spermatic cord does not appear to guarantee spontaneous unraveling of the torsed cord, and attempts at manual reduction should always follow. The opportunity for increased blood flow should improve with stretching alone even if spontaneous unraveling does not occur.
This new technique has the potential to increase practitioner confidence in performing the manual reduction procedure for testicular torsion. It can be used as the first step of manual reduction or as a helpful adjunct when attempts at testicular torsion reduction have failed. Don't forget the critical role of ultrasound to document improved blood flow in the testicle and an uncoiled spermatic cord.
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Dr. Mellickis a professor of emergency medicine, the vice chairman for academic affairs in emergency medicine, the section chief of pediatric emergency medicine, and the assistant residency program director at the University of South Alabama in Mobile. Read his monthly blog athttp://bit.ly/EMN-Mellick, and follow him on Twitter@Lmellick.