Testicular torsion: direction, degree, duration and disinformation

We reviewed and contrast with the literature the cumulative clinical experience at our pediatric urological division in the last 20 years with managing testicular torsion, focusing specifically on the direction and degree of testicular torsion and the duration of symptoms before presentation. We also addressed the incidence of gastrointestinal symptoms, role of manual detorsion, residual torsion and incidence of atrophy.

We reviewed the medical records of 200 consecutive males 18 months to 20 years old who underwent surgical exploration by a pediatric urologist for a diagnosis of testicular torsion between 1980 and 2000.

Of 186 nonelective explorations symptoms were localized to the left side in 52% and to the right side in 48%. Information on the direction and degree of testicular rotation was available in 162 of 186 cases (87%) and anticipated medial rotation occurred in only 108 (67%). Lateral rotation in 54 of 162 cases (33%) occurred in 28 of 84 (33%) with left torsion and in 26 of 78 (33%) with right torsion. A median of 540 degrees of torsion (range 180 to 1,080) was noted in the 70 orchiectomy cases (38%) and a median of 360 degrees (range 180 to 1,080) was noted in the 116 salvaged testes (62%). Manual detorsion was attempted in 53 orchiopexy cases with residual torsion in 17 (32%). Testicular atrophy developed in 27% of the patients.

The traditional teaching that testicular torsion occurs primarily in the medial direction is misleading since in a third of cases it occurs in the lateral direction. While manual detorsion should be guided by response and return of normal anatomy, surgical exploration remains necessary since residual torsion still poses a risk to testicular viability. Long-term followup is warranted to assess the true incidence of subsequent atrophy after the management of acute testicular torsion.