M2E Too! Mellick's Multimedia EduBlog

The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Monday, July 3, 2017

Survival of a Torsed Testicle

The time for possible salvage and survival of a torsed testicle is commonly thought to be six to eight hours, a period that is expressed with confidence by the medical and legal professions. Survival of torsed testicles with and without subsequent atrophy is known to occur outside that critical window. My colleagues recently treated a 17-year-old boy approximately three days after the onset of right scrotal pain. He reported his pain constantly as 8/10 in severity. He didn't tell his mother for several days because he was scared, embarrassed, and hoping that the pain and swelling would resolve.

The patient was taken to the operating room approximately 70 hours after the onset of his testicular torsion. The cyanotic, 360-degree torsed left testicle pinked up and was deemed viable in the OR. The patient reported a week later that he was experiencing no pain and that his testicle seemed to be completely back to normal. Consider for a minute if the urologist had elected not to take the patient to the operating room that night. The outcome would have been much different, and an otherwise salvageable testicle would have died.

The potential for subsequent testicular atrophy is acknowledged, but no one knows for sure. Is there a clear-cut time when it is futile to rush to the operating room? If there is, it probably has to be based on other physical and ultrasonographic findings in addition to time.

It is true that torsed testes have been found to be necrotic after just six or fewer hours of pain, and scores of reports describe testicular survival following significantly longer periods. Many of these salvaged testicles have subsequently atrophied, but some also appear normal despite prolonged periods of torsion. Possible explanations for variations in testicular survival include fewer twists of the spermatic cord, the relative thickness of the torsed spermatic cord, or other anatomical aspects such as the attachment level of the tunica albuginea in the bell clapper deformity that allows persistence of critical blood flow.

The importance of understanding survival time in testicular torsion is critical; failure to recognize that testicular survival can occur even after many hours and potentially days of symptoms can lead to inappropriate delays in timely management. I am working on a systematic review of testicular survival rates and duration of torsion, and a preliminary but extensive search of the literature found 1,857 patients with surprising results. These numbers may change once our systematic review is finished, but time to surgery varied. Our tallied survival was 97.8 percent in patients whose treatment was zero to six hours since onset of symptoms, 83.1 percent for seven to 12 hours, 62.9 percent for 13-18 hours, 44.6 percent for 19-24 hours, 22.5 percent for 24-48 hours, and 7.7 percent for more than 48 hours. These survivals are almost identical to those reported by Visser, et al. (BJU Int 2003;92[3]:200.) Unfortunately, no references were included to support this graphically presented data. Our systematic review has more than 2,000 patients to date, and the survival data remains pretty much unchanged.

The question remains, however, why some torsed testicles appear to be necrotic even though the pain was less than six hours. Based on evidence that suggests this is more commonly seen in younger patients and because some patients have pain honeymoons, it is my opinion that the dead testicles had actually been torsed for much longer.​

I am confident the data are going to prove that we should not give up when suspected testicular torsion patients present many hours past the commonly taught six to eight hours. We will have done our patients and their torsed testicles a huge favor if we will aggressively and expediently manage their initial care in the emergency department.

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Watch a video of Dr. Mellick discussing torsion in a 14-year-old.​

Watch a video of Dr. Mellick discussing an unusual presentation of torsion in a 15-year-old.​​