Purpose: A nine question survey was established on an internet survey provider, aimed to understand attitudes to two principle aspects of management of testicular torsion. Respondents were asked about their experience and attitude toward the use of preoperative manual detorsion, the analgesic usage for that manoeuvre and the approach to the significantly ischaemic testicle at the time of scrotal exploration.
Materials and Methods: A monkey survey platform included 9 questions, the results of which were analysed via an access database. In all, 561 emails were sent from the authors, and the numbers linked via the Australasian Urology and Paediatric Surgery societies, for privacy reasons, were not defined. A total of 285 responses were collected; 181 via emails responses and 104 via a web link.
Results: Results of 285 who did respond, 134are Urologists, 33 Urology trainees, 45Paediatric Urologists,58Paediatric Surgeons and 15 Paediatric Surgery trainees.19 of 58 (32.8%) of Paediatric surgeons, 32 of 45 (66.7%) Paediatric Urologists and 84of 134 (62.7%) of Urologists had untwisted a testicle before theatre, but 12 (25.0%) of 48 trainees have either never been taught or do not believe in the manual detorsion; 46.7% of those in Paediatric Surgery compared to four of 33 urology trainees 15.1%.
Conclusion: The majority of surgeons rely on manual detorsion of the testicle as part of the management of patients with a twisted testicle in the adolescent age group, and there appear to clinical criteria that are used to assess the appropriateness of the manoeuvre.
Testicular torsion occurs in 1 in 4000 males before the age of 25 years , but despite the common occurrence and multiple papers published on the use of manual detorsion there appear to be strong views against the use of the technique, and a wide variation between the different specialties in how to manage testicular torsion patients. Certainly, there are not any public education programs to ensure teenage boys know how to self detort a twisted testicle, despite the high testicular loss rate from torsion [2-3] and the high incidence of litigation when testicular loss occurs.
How to manage the infracted and ischemic testicle like-wise seems opinionated, rather than based on science as highlighted in studies of the testis compartment syndrome [1-4], which is managed by incision by most and insertion of tunica vaginalis in recent studies [1-4].
There are a number of anaesthetic techniques advocated by respondents to the survey, but little literature on the subject[5-6]. And, many are sceptical about the need cause to cause severe pain when they optimistically reflect on easy access to theatre, a view that fails to appreciate that most patients attend a non-hospital practitioner prior to arriving in the emergency department, therefore it would be important for the community, and community health workers, to be aware of a procedure that would buy time. There are now many papers that advocate manual detorsion [5-12] including publications from the 19th Century .
A further barrier to the use of preoperative manual detorsion appears to be uncertainty about the direction of the twist. However, this does not appear to be a problem in the clinical setting, as it the instant pain relief is a marker of the direction in the early presentation cases. Several studies have documented the direction, with most authors noting medial rotation as partof the pathophysiology that is solved by laterally rotating thetesticle in the majority of boys, but not all [5,7,9].
To understand the range of views from those specialtiesthat care of these young men, a brief survey was constructed toascertain both the attitude and experience of manual detorsionfrom the different craft groups, namely, Paediatric Surgeons,Urologists and Paediatric Urologists.
A monkey survey platform included 9 questions, the resultsof which were analysed via a Microsoft Access database.In addition to individual emails, emails to an internationalPaediatric Urology discussion group, the link was provided to theUrological Society of Australasia, members of the South AfricanUrological Association, the Australasian Paediatric SurgerySociety. In all, 561 emails were sent from the authors, and thenumbers linked via the Australasian Urology and PaediatricSurgery societies, for privacy reasons, were not defined.
A total of 285 responses were collected; 181 via emailsresponses and 104 via a web link. Of those 533 contacted directlyfrom the survey team 22 opted out, 23 emails bounced, 159 wereunopened, and of the 329 were opened 181 were completed. Theother 104 completed responses were via a web link provided tomembers of the Australasian Urology and Paediatric Surgerysocieties. The literature was reviewed through Medline and theservice of the University of Cape Town and the Royal AustralasianCollege of Surgeons.
Results of 285 who did respond, 134 are Urologists, 33Urology trainees, 45 Paediatric Urologists, 58 PaediatricSurgeons and 15 Paediatric Surgery trainees.167 trainedsurgeons were more than 10 years post-graduation, of whom96 (57.5%) had untwisted a testicle before theatre; 19 (11.4%)had untwisted a testicle in many patients. 19 of 58 (32.8%) ofPaediatric surgeons, 32 of 45 (66.7%) Paediatric Urologists and84 of 134 (62.7%) of Urologists had untwisted a testicle beforetheatre, which by country showed 19 of 26 (73%) USA surgeons,83 of 107 (77.6%) of South African surgeons and only 23 of74 (31%) Australian surgeons have untwisted a testicle beforetheatre, but only one of 15 (6.7%) Paediatric surgical trainees,most of them are Australian. Twelve (25.0%) of 48 traineeshave either never been taught or do not believe in the manualdetorsion; 46.7% of those in Paediatric Surgery compared tofour of 33 urology trainees 15.1% of the 126 of 285 who hadnot untwisted a testicle before theatre, 5 asserted that there wasno waiting time to get into theatre, 24 of 285 (8.4%) had neverbeen taught and 47 (16.5%) contended they do not believe it tobe appropriate, which included 5 of those who have never beentaught, one who had previously detorted testes off those who douse manual detorsion, 63 of the 159 (41.0%) would not attempt manual preoperative detorsion if there was scrotal oedema, anadditional 64 (40.2%) regarded severe pain as an exclusion, 7reported they would always try.
At the time of the manual detorsion 113 (71.1%) do not useanalgesia, 26 (16.4%) use local and 22 (13.8%) use nitrous oxideor intravenous agents, without local anaesthetic. At the time ofexploration 159 (66.7%) would be inclined to incise the tunicaas a matter of course if considering retaining the testicle, 154(54.0%) would only remove the testicle if it were obviously deador did not bleed with incision of the tunica. Six would neverremove the testicle.
Our study related to four aspects of the care of patientswith intratunical testicular torsion; the use and attitude towarddetorsion, the role of analgesia, the management of a testicle ina marginal state after detorsion, and the decision making relatedto, and the role of, orchidectomy. In 1893, Nash described thecase of a 19 year old school boy with acute pain in the testis whohas his pain relieved by manual detorsion13, being the first tostate the dilemma about the direction to rotate to untwist thetesticle. “I rotated the epididymis in front of the testicle to thepatient’s left, but it caused more pain and would not stay in thatposition. I next rotated it to the patient’s right, so that it resumedits normal position behind the body of the testis. A series of threecases were then presented in 1898 .Since then it has becomeapparent that most testes rotate medial and untwisted laterally,but not all [5-7], with resolving the twist being by externalrotation in the majority [14-15].
Those responding to the survey reported that they wereconcerned that it was not possible to identify that the twist hasbeen completely resolved, and others suggested the procedureis too painful. Incomplete detorsion have been recorded but isuncommon, and with the proviso that the presentation is early,detorsion seems reliable and quick, so quick that most surgeonsin the survey do not take extra “ischemic” time to enableprovision of pain relief, but rely on the instant pain relief thatoccurs with the manual detorsion in those cases without scrotalredness and oedema. A number of authors have presented anumber of analgesic alternatives, including regional blockade. The responses in the survey included 36 practitioners whouse local anaesthetic, 11 uses nitrous, 19 others use other agentsincluding morphine.
The provocative question in our study related to the attitudetoward manual detorsion; despite the number of studiesindicating that the technique can be successful in selected cases,10 surgeons argued that the availability of theatre precludedthe use of the manual detorsion, while 47 stated they “did notbelieve in it”, or had not been trained, particularly AustralasianPaediatric Surgeons, noting however that the survey was not sentto all specialists in all geographical areas. Disappointingly, 25 claimed to have “never been trained” in a technique that clearlyhas a good track record, and strong support of the majority ofclinicians involved in care of these patients. Notable 5 of thosewho had never been trained “did not believe in it”, which mightreasonably be thought to lack an open minded approach totherapeutic options.
It is known that the two most important factors determiningtesticular damage are the time from the onset of symptomsto the reduction of torsion, and the degree of twisting in thecord. Experimental studies in dogs show the elimination ofall spermatogenic and Sertoli cells by six hours of testicularischaemia, and the elimination of Leydig cells by 10 h of ischemia. Some degree of atrophy is almost inevitable after torsion ofmore than four hours duration. Infarction can occur as early asfour hours if the cord has twisted through several revolutions.After 10 hours of torsion most patients will have significantatrophy, unless the torsion was limited to 180–360° . Withtorsion of more than 360° lasting more than 24 hours all patientswill have complete or severe atrophy .
Moreover, it is known that unilateral testicular torsioninterferes with subsequent spermatogenesis. The sperm countand the degree of atrophy both correlate closely with theduration of torsion . Patients who have atrophy or whohave undergone orchidectomy have a significantly lower spermcount than those without atrophy . Abnormalities notedin the contra lateral testis include extensive apoptosis in thegerminal epithelium, atrophic Leydig cells, malformation of thelate spermatids, fewer late spermatids, and pathological changesin Sertoli cells. Trauma to the blood–testis barrier initiated bytorsion may induce the release of cytokines, which damage thecontra lateral germinal epithelium .
While easy access to theatre allows for definitive management,the reality is that the mean time between presentation andintraoperative detorsion often varies between 1 to 7 hours, evenin areas where healthcare is well developed, and best communitycare would result in teenage boys being aware of the diagnosis,using their mobile phone camera to document the pathologyand untwisting the testicle themselves, alternatively the primarycare physician doing likewise. The primary pathophysiologicalevent in testicular torsion is ischemia of the testis followed byreperfusion after detorsion . Thus, testicular torsion can bethought of as an ischemia/reperfusion injury to the testis.
Repair of testicular torsion is followed by a period ofgerm cell apoptosis, accumulation of testicular neutrophilsand increased testicular oxidative stress. Testicular vascularE-selectin expression is increased after de-torsion as are anumber of cytokines important in the recruitment of neutrophils. The testis is covered by the tunica albuginea, a fairly strongand inelastic layer. As a result, tissue changes from ischemiareperfusionleads to oedema, increased intratesticular pressure and reduced perfusion pressure. Hence perpetuating testicularischemia . This has been termed the testicular compartmentsyndrome.
The latter part of the study questionnaire sort to understandsurgical management of a testicle in a marginal state afterdetorsion, and the decision making related to, and the role of,orchidectomy. Traditional intraoperative management involvedeither detorsion and orchidopexy or orchidectomy depending onthe subjective assessment of testicular viability by the surgeon.Recently a new method involving incision of the tunica albugineaand flap coverage with Tunica Vaginalis was described. Thisdirectly addresses the testicular compartment syndrome andmay improve testicular salvage rates. 190 surgeons indicatedthat they would incise the tunica in an ischemic testicle, whichhas been investigated by at least two groups, who suggest theuse of covering the exposed tissue with tunica vaginalis [1,4]. 85surgeons do not incise the tunica, but others present argumentfor variable use of incision on the clinical scenario, which seemsa rational, more guarded approach.
Interestingly, six surgeons would never remove an infarctedtesticle, 124 would always remove the testicle, but not incisethe testicle before doing so. The other 139 surgeons and traineewould incise the tunica first to check for viability before makingthe final decision to perform an orchidectomy. Clearly, more workneeds to be done to understand the outcome for the dead testicleleft behind, and the determinant of viability to help developpatient specific international guidelines–particularly focussedon the understanding that no two patients are the same.
The majority of surgeons rely on manual detorsion of thetesticle as part of the management of patients with a twistedtesticle in the adolescent age group, and there appear to beclinical criteria that are used to assess the appropriateness ofthe manoeuvre. However, it would also appear the technique isnot as widely used as possible with a particular concern thattrainees in both surgery and urology have either never beentaught or “don’t believe” in the technique felt appropriate by themajority.
Given the success of the technique as published since 1893,the ability of some patients to untwist their own torsion, itwould seem improved community, general practitioner andspeciality knowledge of the first aide for twisted testicles wouldbe appropriate. What should be done when a torsion case gets totheatre, and how the degree of damage should be assessed at thenecessary surgical intervention subsequently, obviously needsto be subjected to enhanced scientific rigor.