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Practical Urology: EssEntial PrinciPlEs and PracticE

high-frequency transducer sonography includ-

Torsed testicular appendages should be man-

ing pulsed and color Doppler vascular imaging.3

aged conservatively with analgesics. The pain

A 50% false-positive rate has been reported for

resolves in 2–3 days with atrophy and some-

the diagnosis of testicular torsion when the

times calcification of the appendage.

diagnosis is made solely on the basis of clinical

findings, without the use of imaging.80 Color

Treatment of Spermatic Cord Torsion

Doppler ultrasound is very useful to quantitate

intratesticular blood flow.81 Color Doppler was

The ability to salvage a torsed testicle depends

86% sensitive, 100% specific, and 97% accurate

on the duration and degree of torsion. If the

in diagnosing testicular torsion in patients with

diagnosis is made and intervention occurs

a painful scrotum when detection of intrates-

within the first 6 hours after the onset of symp-

ticular flow was the only criterion utilized.82

toms, there is a nearly 100% testicular salvage

Subtraction dynamic-contrast enhanced MRI

rate. Testicular salvage drops to 70% in the

has been utilized to evaluate patients for testicu-

6–12 hours time frame, and is diminished to

lar torsion. Decreased testicular perfusion and

20% between 12 and 24 hours.87 Age is a signifi-

hemorrhagic necrosis can be determined with

cant predictable risk factor for orchiectomy in

MRI.83 Scrotal MRI however is presently not a

patients between the ages of one and 25 with

time or cost-effective adjunct to the diagnosis of

testicular torsion, due to the delay in seeking

the acute scrotum.

medical attention in older males.88 Immediate

Torsion of the testicular appendix is the most

surgical exploration and bilateral orchiopexy is

common cause of the acute scrotum in chil-

the treatment of choice in acute testicular tor-

dren.84 Of all appendiceal torsions, 91–95%

sion, although orchiectomy is required with

involve the appendix testis, and most commonly

delayed treatment with subsequently infarcted

are seen in boys between 7 and 14 years of age.3

or necrotic testicles.89 Emergency exploration

The clinical appearance of torsion of the tes-

should be undertaken, and ideally, bilateral

ticular or epididymal appendages is similar to

orchiopexy should be performed if the torqued

that of testicular torsion, but often with a grad-

testis is found to be viable. Orchiectomy and

ual onset of pain.On physical examination,there

contralateral orchiopexy should be performed if

is typically a palpable small, firm nodule on the

the testis is not viable. Manual detorsion should

superior portion of the testis. The classic “blue

be performed if surgical exploration is to be

dot sign” refers to bluish discoloration of the

delayed.69 Manual detorsion is performed by

appendix, which is visible through the overlying

external rotation of the torqued testis with con-

skin.85 Unlike in testicular torsion, the cremas-

firmation of intraparenchymal blood flow fol-

teric reflex is still present with torsions of the

lowing detorsion.64 Manual detorsion is often

scrotal appendices.

accompanied by significant and instantaneous

Ultrasound is only useful in cases of appen-

relief of symptoms. Orchiopexy is also recom-

diceal torsion without a clear diagnosis based

mended in these patients.

on clinical findings. The typical sonographic

Patients with intermittent testicular torsion

findings in torsion of the appendix include a cir-

should undergo elective bilateral orchiopexy. If

cular mass adjacent to the testis or epididymis,

untreated, these patients are at risk for develop-

with variable echogenicity.85 There may be

ing an episode of complete testicular torsion

peripheral flow by color Doppler around the

with subsequent infarction and testicular loss.71

torqued testicular appendage, and a reactive

Ninety-seven percent of patients treated with

hydrocele with skin thickening is not uncom-

prophylactic bilateral orchiopexy have complete

mon.81 Ultrasound findings may also include

resolution of their symptoms with a high likeli-

larger testicular appendages than controls, mea-

hood of preventing future infarction.72

suring 5 mm or greater, which are spherical in

Some authors feel that urgent surgical explo-

shape, and with increased periappendiceal

ration and concomitant contralateral orchio-

blood flow. Ultrasound cannot demonstrate

pexy is indicated in the case of acute neonatal

blood flow in the torsed or in the normal appen-

testicular torsion.90 The risk of testicular loss

dix testis and there is no difference in echoge-

must be balanced with the risk of anesthesia in

nicity between the normal and the torsed

neonates with testicular torsion. Testicles noted

appendix testis.86

to have extravaginal torsion at the time of