Prehospital Emergencies: Testicular Torsion

Introduction

While testicular and male GU emergencies in general are rare and even rarer for EMS to encounter, there are several specific can’t-miss emergencies that we must all be familiar with. While no specific prehospital treatment exists for testicular torsion, it is important for providers both BLS and ALS to be familiar with the recognition of torsion and the hospital treatment path for it once the patient leaves our stretcher.

Incidence

Per StatPearls, scrotal complaints alone make up only 0.5 percent yearly of emergency department visits - and even less for EMS calls. Testicular torsion occurs most commonly with males age 13-14 years old at a rate of 1 in 4000 (Laher et al., 2020). Testicular torsion is most commonly associated with heavy activity in teenage males such as weightlifting, soccer, and football games. However, it can occur at rest or with no activity at all.

Pathophysiology

Under normal circumstances, the testes are connected to and perfused by the spermatic cord, a long structure that contains the testicular arteries. The testicular arteries themselves are connected to the renal arteries and eventually are branched into the descending lower aorta itself.

When the testes twist around the spermatic cord, this becomes testicular torsion. When this occurs, blood flow to the testes is occluded - resulting in tissue ischemia and deprivation of oxygen/nutrients to the testes themselves. Within hours, this can cause necrosis of the tissue and eventually lead to loss of the affected testicle entirely. Most rotations are between 90 and 180 degrees with higher degrees of rotation leading to worse outcomes (Schick, 2023).

Torsion itself does not immediately produce ischemia - in fact, studies found that the average onset time for the development of ischemia following torsion occurrence was between 4-8 hours (Laher et al., 2020). As time goes on, further damage is done to the testes.

As ischemia worsens, cell permeability within the soft tissue increases - resulting in potassium ions shifting into the extracellular space in addition to other solutes. Anaerobic metabolism also occurs, producing toxic metabolic byproducts such as lactic acid. All of these components combine to worsen and further progress the ischemia, creating a positive feedback loop that can only be corrected/halted by restoring blood flow to the area.

Assessment

As stated above, testicular torsion can be present in any age group but is most common with men that are active. You should be particularly suspicious for testicular torsion with history presentations such as sudden onset groin and abdominal pain following a soccer game or weightlifting session, for instance.

Common testicular torsion findings also include nausea/vomiting, severe groin and abdominal pain, scrotal edema, tenderness in the area, and redness (Laher et al., 2020). Unilateral abdominal/groin pain should make you particularly suspicious for the presence of torsion.

Remember - these patients are going to be in severe pain.

There are also specific clinical signs for testicular torsion.

• Cremasteric sign - Under normal conditions, the ipsilateral testicle should lift when pinching the inner thigh of a patient. If this lift is present, then torsion is unlikely. Patients should be able to describe that this lifting is occurring even without direct visualization (Sharp, 2013).

• Brunzul’s sign - One of the clinical signs for testicular torsion is a high riding or elevated sole testicle. The patient should be able to describe this to you if they physically examined themselves in the mirror when the pain onset (Wu et al., 2019)
  

It is also important to remember that pain can be intermittent or transient in nature. If the testicular is not fully complete, then patients may have temporary or periodic relief as the cord is spontaneously untwisted. However, testicular torsion does not resolve itself and is a surgical emergency.

Formal Diagnosis & Hospital Treatment

Testicular torsion is often a clinical diagnosis - meaning that it is diagnosed off the signs and symptoms alone. However, the gold standard for confirmation is doppler flow assessment of the affected testes in addition to ultrasound visualization. This can be done in any ultrasound-capable ER.

Once the patient is brought to the hospital, they are brought to the OR and given a procedure called orchiopexy - which is the surgical untwisting of the affected testes followed by stitching the testicle wall to avoid recurrence (Schick, 2023).

Why this matters for EMS

There are two critical roles that EMS can play in managing this emergency; pain management and proper recognition. For many EMS providers, a complaint of testicular pain is easy to shrug off as being BLS or appropriate for referral to an alternative transport destination such as a freestanding ER or even an urgent care. Many providers would also associate any genital pain of any sort as potentially STI-related and thus a nonemergency for EMS standards.

For orchiopexy surgery to be successful, it must be performed ideally within 6 hours of testicular torsion onset (Schick, 2023). Per Shick, the recovery rate is almost 100 percent if testicular torsion is identified and surgically corrected within this timeframe. Tissue recovery drops precipitously after the 6-8 hour marks. If surgery is not performed in time, then loss of the testicle is likely.

However, patients that are brought to an inappropriate transport destination like a freestanding ER can have a significant negative effect on their care. A freestanding ER that is not capable of urologic surgery is able to do nothing for a patient with this ailment. With freestanding ERs sometimes taking hours to diagnose and be able to actually transfer a patient via interfacility services, the patient will continue to become ischemic and the extent of damage worsen. It is critically important to choose a transport destination that is capable of urologic surgery with a capable OR for any patient complaining of severe abdominal or groin pain.

In addition, these patients are going to be in severe, excruciating, and often relentless pain. Pain management is one of the core things that EMS can do to improve patient quality of life and potentially improve outcomes. While there is no specific literature linking proper pain management to better tissue outcomes, pain management improves patient quality of life and helps reduce the sense of urgency felt by the patient while still allowing for adequate care to be delivered.

Closing

Do you think that you would recognize a testicular torsion emergency prehospital? Do you feel that this article has helped you to better serve this population as an EMS provider? Let me know.

Works Cited

Laher, A. E., Ragavan, S., Mehta, P., & Adam, A. (2020). <p>Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies</p> Open Access Emergency Medicine, Volume 12, 237–246. https://doi.org/10.2147/oaem.s236767

Schick, M. A. (2023, June 12). Testicular torsion. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK448199/

Sharp, V. J. (2013, December 15). Testicular torsion: diagnosis, evaluation, and management. AAFP. https://www.aafp.org/pubs/afp/issues/2013/1215/p835.html

Wu, Y., Hsu, C. W., Du, M., & Huang, W. (2019). Young man with sudden scrotal pain. Annals of Emergency Medicine, 74(2), 185–250. https://doi.org/10.1016/j.annemergmed.2019.01.043