The Effectiveness of Manual Detorsion Applied in the Emergency Department in Testicular Torsion: A Single - Center Experience of 13 Years

Hulya Yilmaz Baser¹, Kursat Kucuker²

¹Department of Emergency Medicine, Bandirma Onyedi Eylul University School of Medicine, Balikesir, Türkiye
²Department of Urology, Pamukkale University School of Medicine, Denizli, Türkiye

DOI : 10.5505/GJU.2023.81300

Pages : 070-074

Abstract

Objective: As a urological emergency, testicular torsion is one of the causes of acute scrotum in all age groups. This study aimed to evaluate the effectiveness of manual detorsion performed before surgical intervention.

Materials and Methods: Retrospective data analysis of the patients with acute scrotum who applied to the emergency department of a 3rd level hospital between the years January 2010 and January 2023 with the complaint acute unbearable pain within the first 12 hours of its onset was performed. Patients were grouped according to whether or not manual detorsion was performed in the emergency department. Successful manual detorsion was defined as postprocedural normal color Doppler ultrasound findings and complete resolution of pain. All patients had undergone surgical exploration. Age, laterality of the torsional testis, manual testicular detorsion attempt (if any), and surgical conditions resulting in testis preservation or orchiectomy were the patient data analyzed.

Results: Sixty patients were included in the study. Manual detorsion was performed in 29 (48.3%) patients in the emergency department (Group 1). Scrotal exploration was performed in 31 (51.7%) patients without applying manual detorsion (Group 2). In Group 1, testicular preservation was achieved in 26 (89.7%) patients. In Group 1, in 3 patients (10.3%) testicular necrosis occurred due to failure to achieve adequate blood supply, while orchiectomy was performed in 11 (35.5%) patients in Group 2. Lower rates of orchiectomy were observed in Group 1 compared to Group 2 (p=0.021). We also observed that manual detorsion decreased the rate of orchiectomy (rho- 0.297, p=0.021), and the probability of undergoing orchiectomy increased with increasing age (rho 0.512, p<0.001).

Conclusion: Manual testicular detorsion is a noninvasive method that can be safely applied to all patients diagnosed with testicular torsion. We think that it will shorten the duration of testicular ischemia in the emergency department and contribute to testicular salvage.

Introduction

Testicular torsion is defined as twisting of the testis along the spermatic cord resulting in venous congestion and poor arterial supply eventually leading to ischemia [1]. As a urological emergency, it is one of the causes of acute scrotum in all age groups. The overall incidence of testicular torsion in males is 2.02 to 21.76 per 100,000 population [2,3]. Differentiation of testicular torsion from other acute scrotal emergencies is important in terms of fertility and organ preservation. It is most often confused with epididymitis. An abnormal (horizontal) position of the testis is more common in testicular torsion than in epididymitis [4]. Searching for the absence of cremasteric reflex is a simple diagnostic test for testicular torsion with 100% sensitivity and 66% specificity [5,6]. Elevation of the scrotum (testes) may reduce symptoms in epididymitis, but not in testicular torsion. Determining the cause of acute scrotum based on history and physical examination alone is not easy [7]. Although scrotal color Doppler ultrasonography (CDU) is helpful in diagnosis, the possibility of false negatives and variable CDU findings pose a problem in clinical practice [8].

In case of suspected testicular torsion, manual detorsion of the testis is performed without anesthesia and should be attempted in all patients if possible [9]. As long as the pain does not increase or there is no obvious resistance, it should initially be done by turning the testicles outward as if opening a book. Success is defined as the immediate resolution of all symptoms and disappearance of abnormal findings on physical examination [10]. In case of failed attempts at detorsion, emergency surgical treatment is required. Although success rates related to manual testicular detorsion ranging between 61.5%, and 91% have been reported in the literature, residual torsion has been demonstrated in 27-32% of the patients who had undergone manual detorsion [11-13]. With this study, as a contribution to the literature, we aimed to investigate the effectiveness and success rates of manual detorsion in the light of our clinical experience.

Materials and Methods

Study Design and Ethics Approval
This study was designed as a cross-sectional retrospective study. The study protocol was reviewed and approved by the Institutional Review Board of Pamukkale University School of Medicine Ethics Committee (ethics committee approval date and number: 04.04.2023/353797).

Study Population and Data Collection
The medical files of 71 patients who were admitted to the emergency department of Pamukkale University School of Medicine with the complaint of the acute onset of scrotal pain and diagnosed with testicular torsion between the years January 2010 and January 2023 were retrospectively analyzed. Although discrepancies in postoperative outcomes of orchiectomies performed have been reported in the literature, it has been stated that the rates of testicular salvage decrease significantly if intervened 12 hours after onset of pain [13,14]. Therefore, the cases that applied within the first 12 hours after the onset of complaints were included in the study. All patients were diagnosed with testicular torsion by physical examination and CDU. Scrotal exploration was performed in all patients. Testicular fixation was performed in cases with testicular detorsion detected in scrotal exploration, while surgical detorsion and fixation were performed in cases without detorsion. These patients were noted as cases with preserved testis. Orchiectomy was performed in cases with impaired blood supply and testicular necrosis detected during scrotal exploration. Retrospectively, patients who had, and had not undergone manual detorsion in the emergency department were included in Groups 1 and 2, respectively. Successful manual detorsion was defined based on the cessation of pain and the demonstration of adequate testicular blood flow by CDU. The patients" age and laterality of torsioned testis were recorded.

Statistical Analysis
Statistical analyses were performed using the SPSS version 22 software. The fitness of variables to normal distribution was tested using the Shapiro-Wilk test. Descriptive statistics were expressed as mean and standard deviation for variables with normal distribution, median, minimum and maximum values for ordered ordinal data, and numbers and percentages for categorical variables. In the evaluation of numerical data between the groups, the parameters with normal distribution were evaluated with Student t-test, ordinal data with Mann- Whitney U test, and categorical data with chi-square test. The correlations between the orchiectomy and application of manual detorsion, age, laterality of torsioned testis were analyzed using the Spearman correlation coefficients. The model fit was analyzed using the required residual and fit statistics. The cases with a type-1 error level below 0.5% were statistically interpreted.

Results

Sixty patients admitted to the emergency department with the diagnosis of testicular torsion within the first 12 hours of onset of acute scrotum in the last 13 years were included in the study. The mean age of 60 patients was 23.45 ± 7.27 years. Right testicular torsion was observed in 31 (51.7%), and left testicular torsion in 29 (48.3%) patients. Orchiectomy was performed in 14 (23.3%) patients. Twenty-nine (48.3%) patients had undergone manual detorsion in the emergency department (Group 1), and scrotal exploration had been performed in 31 (51.7%) patients without manual detorsion (Group 2). Testicular fixation was performed in 19 (65.5%) of 29 patients in Group 1, whose testicular blood flow was normal during scrotal exploration (Figure 1). In 7 (24.1%) patients in Group 1, manual detorsion was not found to be sufficiently effective during exploration, and surgical detorsion together with testicular fixation was applied (Figure 2). Testicular preservation was achieved in a total of 26 (89.7%) patients. In Group 1, 3 patients (10.3%) had testicular necrosis and since testicular blood supply did not improve, orchiectomy was performed, while in Group 2, 11 (35.5%) patients underwent orchiectomy (Figure 3). The characteristics of the groups are shown in Table 1.

Figure 1. Appearance after surgical detorsion

Figure 2. Appearance before surgical detorsion

Figure 3. Necrotic testis appearance before orchiectomy

Table 1. The characteristics of the groups

There was no difference between the groups in terms of age and laterality of testicular torsion (p=0.994 and p=0.611, respectively). Patients who underwent manual detorsion in the emergency department (Group 1) were less likely to undergo orchiectomy than those who did not (Group 2) (p=0.021).

In the correlation analysis between the application of orchiectomy and age at orchiectomy, laterality of testicular torsion, and manual detorsion; we observed that manual detorsion decreased the orchiectomy rates (rho- 0.297, p=0.021), and the probability of undergoing orchiectomy increased with increasing age (rho 0.512, p<0.001).

Discussion

Testicular torsion is an emergency that requires urgent surgical treatment. It is the second most common cause of acute scrotum in children and adolescents [12]. The two most important determinants of early testicular salvage rate are the time elapsed between symptom onset and detorsion and the degree of torsion [15]. Apart from these, in studies conducted in Ireland and Korea, age (infancy and advanced age), lack of private insurance, place of residence far away from healthcare facilities and transfer from another hospital were associated with increased rates of orchiectomy [2,3]. In our study, a positive correlation was found between increasing age and rates of orchiectomy, although the neonatal group was not fully evaluated since it was not the group in which we intervened. Rates of testicular salvage after testicular torsion were reported as 75.22-76% in South Korea [2,16], 84% in Ireland [3], 58-68% in the USA [17-19], and 74% in Taiwan [20]. In our study, in consistent with the literature data, rates of testicular salvage were 89.7%, and 64.5% in those who had, and had not undergone manual detorsion, respectively with an overall testicular salvage rate of 76.7%. In a study the success rate of manual detorsion reported based on evaluation of scrotal color Doppler ultrasound scan results was reported as 61.5%, which was lower than our testicular salvage rates [11]. In their study, S. Vasconcelos-Castro et al. reported results similar to ours. In other words, testicular preservation was achieved in 91% of the patients who had, and in 56% of them who had not undergone manual detorsion [12].

Manual detorsion is a known noninvasive and effective maneuver since it was first described by Nash in 1893 who reported its advantage in testicular preservation [9,10,21-25]. Manual detorsion is always recommended in patients diagnosed with testicular torsion clinically and/or with CDU so as to restore testicular blood flow as soon as possible and to refrain from orchiectomy [12]. With the patient overload of the emergency system and the delay in consultation, surprisingly we observed that manual detorsion was not applied in the emergency departments. Testicular torsion should be suspected in patients presenting with an acute scrotum until proven otherwise. The potential risk of other possible causes causing testicular torsion in a patient presenting with an acute scrotum is theoretically possible but very unlikely, and has been never previously reported [26]. In addition, any attempt to rotate a testicle without testicular torsion, even if suspected, or manual detorsion in the wrong direction causes or increases pain [10,27]. It has been stated that manual detorsion to be applied in the emergency department will reduce testicular loss [9]. Manivel et al. [28] stated that it is important to teach and apply manual detorsion to general practitioners who intervene in the acute scrotum. We think that manual detorsion will be beneficial for the preservation of testicles during the referral of patients who cannot undergo urology consultation and/or CDU in the emergency department.

This study has some limitations such as the pediatric age group was not included in the study, the patients were intervened within at most 1 hour after onset of their symptoms, and duration of testicular torsion could not be exactly determined due to the missing retrospective data. In addition, the lack of longterm follow-up results, and inability to differentiate between intravaginal / extravaginal testicular torsion can be stated as a limitation of the study.

Conclusion

Manual detorsion is a noninvasive method that can be safely applied to all patients diagnosed with testicular torsion. We think that manual detorsion will reduce the longevity of testicular ischemia and contribute to testicular salvage, both in the waiting period for consultation in the emergency department and in patients who will be referred to an advanced medical center.

Ethics Committee Approval: The study protocol was reviewed and approved by the Institutional Review Board of Pamukkale University School of Medicine Ethics Committee (ethics committee approval date and number: 04.04.2023/353797).

Informed Consent: An informed consent was obtained from all the patients.

Publication: The results of the study were not published in full or in part in form of abstracts.

Peer-review: Externally peer-reviewed.

Authorship Contributions: Any contribution was not made by any individual not listed as an author. Concept – H.Y.B., K.K.; Design – H.Y.B., K.K.; Supervision – H.Y.B., K.K.; Resources – H.Y.B., K.K.; Materials – H.Y.B., K.K.; Data Collection and/or Processing – H.Y.B., K.K.; Analysis and/ or Interpretation – H.Y.B., K.K.; Literature Search – H.Y.B., K.K.; Writing Manuscript – H.Y.B., K.K.; Critical Review – H.Y.B., K.K.

Conflict of Interest: The authors declare that they have no conflicts of interest.

Financial Disclosure: The authors state that they have not received any funding.