Manual Testicular Detorsion

Testicular torsion

Signs and symptoms include:

Acute scrotal pain/swelling or intermittent testicular pain

Testicular tenderness

High-riding testis with horizontal lie

Absent cremasteric reflex on the affected side

Negative Prehn sign (no relief of pain upon elevation of the testis)

Manual detorsion may serve as a temporizing measure to reperfuse the testis while the patient is awaiting definitive surgical management. A urologist or general surgeon should be consulted immediately when torsion is suspected to prepare for emergency surgery.

CONTRAINDICATIONS

Manual detorsion should not delay scrotal exploration and bilateral orchiopexy in the operating room (OR)

Spermatic cord anesthesia should be used only after discussing with the consulting urologist because it may blunt the subjective end point of detorsion efforts (relief of pain)

RISKS/CONSENT ISSUES

Pain (sedation and local anesthesia may be used)

Local bleeding and/or infection if spermatic cord anesthesia is administered

Manual detorsion does not replace the absolute need for surgical scrotal exploration/orchiopexy

LANDMARKS

If considering spermatic cord anesthesia/block, identify the spermatic cord at the external inguinal ring. Alternatively, if severe edema is present, palpate cord at pubic tubercle over pubis.

General Basic Steps

Patient preparation

Local anesthesia (optional)

Detorsion

Confirmation

TECHNIQUE

Patient Preparation

Place the patient in reclining, supine, or lithotomy position

Consider light procedural sedation

Local Anesthesia (optional)

Ensure that the consulting urologist or general surgeon does not object to providing local anesthesia

Spermatic Cord Block

Sterilize the skin overlying the spermatic cord

Insert small (30-gauge) needle directly into the spermatic cord (FIGURE 35.1)

Aspirate for blood to ensure the needle is not intravascular

Slowly inject 10 mL of 1% plain lidocaine (maximum 3 mg/kg)

Detorsion

The most common direction for torsion to occur is lateral to medial

The initial attempt at detorsion should therefore be medial to lateral (FIGURES 35.2 and 35.3). Imagine you are “opening a book.”

Multiple rotations of the testicle may be necessary for complete detorsion; the degree of torsion may be guided by the patient’s pain relief

One-third of cases are torsed in the opposite direction. If initial detorsion efforts appear ineffective/painful, attempt to detorse laterally to medially.