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Keywords:

  • Testicular torsion;
  • therapy;
  • manual derotation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

Objective

To re-emphasize the safety and efficacy of manual derotation in the management of the twisted spermatic cord.

Patients and methods

Seventeen patients (mean age 15 years, range 13–28) with acute unilateral torsion of the spermatic cord, initially treated by manual detorsion, were reviewed; all 17 patients were seen by one consulting urologist (H.F.M.K.).

Results

In 14 of the 17 patients the attempt resulted in successful manual derotation, i.e. the immediate relief of all symptoms and normal findings at physical examination. No testicular atrophy was detected during the follow-up (mean 22 months, range 9–72).

Conclusions

These results reinforce the efficacy and safety of manual derotation with subsequent elective bilateral orchidopexy as the primary treatment for the twisted spermatic cord.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

Torsion of the spermatic cord is a urological emergency, with early diagnosis and derotation of vital importance in preventing ischaemic damage. Most testes are salvaged if the normal blood supply is restored within 6 h [ 1, 2]. In 1893, Nash [ 3] described successful manipulative reduction of the twisted spermatic cord as an alternative to emergency surgical exploration. Since 1966, 15 different groups have described the efficacy and safety of this procedure in case reports or small series. Nevertheless, the last report was published in 1988 by Workman and Kogan [ 4]. Surgical exploration and subsequent derotation and orchidopexy or orchidectomy, depending on the viability of the organ, remains the gold standard. In view of the safety, efficacy and speed of the procedure, we reviewed our experience and re-emphasize the importance of this treatment in the management of the twisted spermatic cord.

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

Between January 1991 and December 1996, 61 patients with a clinical diagnosis of unilateral torsion of the spermatic cord were referred to our teaching hospital. The diagnosis was based on a history and physical examination; history revealed acute hemiscrotal pain with in most cases one or more previous episodes of less severe scrotal pain. Nausea and vomiting were common symptoms but no patient had urinary symptoms or fever. On physical examination a high and transverse-lying painful testicle was palpated, together with a thickened spermatic cord. The cremasteric reflex was absent in most cases. As neither Doppler flow ultrasonography nor radionuclide scanning can exclude torsion, these methods were not used in the diagnosis.

Manual derotation, as described by Workman and Kogan [ 4] was attempted in 17 patients (28%) and the other 44 underwent emergency surgical scrotal exploration. All manual derotation procedures were performed or supervised by one of the three urologists (H.F.M.K.), whereas the other 44 patients were seen by the two other consulting urologists. As most testes are twisted inwards, initial derotation was attempted outwards [ 5]. If the pain increased and/or there was resistance, the opposite rotation was attempted. Successful manual derotation was defined as the immediate relief of all symptoms, normal findings at physical examination and no evidence of testicular atrophy during follow-up. These criteria not only defined a successful procedure but also confirmed the diagnosis. Symptoms and signs of epididymo-orchitis or torsion of a hydatid of Morgagni do not resolve on manual derotation. Local anaesthesia was not given because this eliminated the relief of pain as an important indicator of successful detorsion. After manual derotation all patients underwent elective bilateral scrotal orchidopexy. Patient information was obtained at the initial hospitalization, during follow-up visits, by telephone and through the referring physician.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

Manual derotation was initially attempted in 17 patients with a clinical diagnosis of torsion of the spermatic cord (mean age 15 years, range 13–28). The mean (range) time from the onset of symptoms to diagnosis was 4 (1–24) h; two patients had had symptoms for >6 h (15 and 24 h). The torsion was on the right side in nine patients and on the left in eight. To relieve torsion, manual derotation of 180–540° was sufficient and this was performed within 5 min.

In three of the 17 patients manual derotation was discontinued because it was too painful and oedema of the scrotum precluded approaching the twisted testis. At emergency surgical exploration these three testis were viable after derotation and a bilateral orchidopexy was performed.

Bilateral scrotal orchidopexy was performed in all cases of successful manual derotation. The time elapsed between successful manual derotation and bilateral scrotal orchidopexy varied from 2 h to 3 months (mean 12 h). At orchidopexy, all untwisted testes appeared viable and during the follow-up (9–72 months, mean 22) after a scrotal orchidopexy, all untwisted testes remained normal with no evidence of atrophy.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

Manual derotation of the twisted testis is an old concept; in 1893, Nash [ 3] described this procedure and since then several investigators have described the success of this noninvasive manoeuvre [ 3, 5[6][7][8]–9]. However, since 1966, only four series have been published with a total of 74 patients ( Table 1). In 65 of 74 patients (87%) the initial attempt ended in a successful manual derotation [ 6[7]–8, 10]. Most importantly, in 64 of 65 successful derotations (98%), as defined by immediate relief of all symptoms and normal findings at physical examination, the testes were salvaged, as judged during orchidopexy and on follow-up [ 6[7]–8, 10].

Table 1.  Manual detorsion of the twisted spermatic cord; literature review and case series Thumbnail image of

In the present series, all testes were saved after manual derotation; 14 of 17 attempts at manual derotation were successful, as judged by the criteria used. Retorsion of the derotated testis did not occur between the time of manual derotation and elective scrotal orchidopexy in any of the 14 successful manual derotations. These results are comparable with others ( Table 1) [ 6[7]–8, 10].

The present results emphasize that manual derotation is a noninvasive, quick and safe method leading to the desired result, i.e. effective derotation of the twisted spermatic cord and salvage of the involved testis. Nevertheless, manual detorsion is currently seldom used by urologists or emergency-ward doctors. Surgical exploration followed by derotation, bilateral orchidopexy or orchidectomy, the latter depending on the viability of the organ, is still the ‘gold standard’. There are several explanations why this manoeuvre is so unpopular. First, a twisted testis can be extremely painful and thus unapproachable. It is therefore not surprising that due to pain and oedema, three of 17 attempts failed. This problem can be overcome in some patients when the manoeuvre and its advantages are explained clearly to the patient. Second, an orchidopexy is performed in all cases anyway and therefore many doctors find this manoeuvre bothersome. However, torsion of the spermatic cord is a urological emergency and it is important to prevent ischaemic damage of the testis by minimising the duration of ischaemia. After manual derotation, blood flow is immediately restored. Moreover, after successful noninvasive manual derotation this urological emergency now becomes an elective orchidopexy. Third, many doctors are not familiar with the procedure; in our teaching hospital, only one of the three urologists performs it and thus only 17 of the 61 patients diagnosed with torsion of the spermatic cord underwent the procedure. Thus manual detorsion is the treatment of first choice for this urological emergency, being quick, noninvasive, efficient and safe.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References
  • 1
    Allen WR & Brown RB. Torsion of the testis: a review of 58 cases. Br Med J 1966; 1: 1396
  • 2
    Skogland RW, McRoberts JW, Ragde H. Torsion of the spermatic cord: a review of the literature and an analysis of 70 new cases. J Urol 1970; 104: 604
  • 3
    Nash WG. Acute torsion of the spermatic cord: reduction: immediate relief. Br Med J 1893; 1: 742
  • 4
    Workman SJ & Kogan BA. Old and new aspects of testicular torsion. Semin Urol 1988; 6: 146 57
  • 5
    Ransler CW & Allen TD. Torsion of the spermatic cord. Urol Clin North Am 1982; 9: 245 50
  • 6
    Kiesling VJ, Schroeder DE, Pauljev P, Hull J. Spermatic cord block and manual reduction: primary treatment for spermatic cord torsion. J Urol 1984; 132: 921 3
  • 7
    Catolica EV. Preoperative manual detorsion of the torsed spermatic cord. J Urol 1985; 133: 803 5
  • 8
    Lee LM, Wright JE, McLoughlin MG. Testicular torsion in the adult. J Urol 1983; 130: 93 4
  • 9
    Frazier WJ & Bucy JG. Manipulation of torsion of the testicle. J Urol 1975; 114: 410 1
  • 10
    Vordermark JS. Testicular torsion: management with ultrasonic doppler flow detector. Urology 1984; 14: 41 2