Recurrences of testicular torsion after manual detorsion: a single institution experience

Article information

Pediatr Emerg Med J. 2025;12(2):83-86

Publication date (electronic) : 2025 March 10

doi : https://doi.org/10.22470/pemj.2025.01228

Takahiro Hosokawa

Department of Radiology, Saitama Children’s Medical Center, Saitama, Japan

Corresponding author: Takahiro Hosokawa Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama 330-8777, Japan Tel: +81-48-601-2200; E-mail: hosokawa.takahiro@saitama-pho.jp

Received 2025 February 23; Revised 2025 March 4; Accepted 2025 March 4.

Testicular torsion is a surgical emergency requiring prompt detorsion to prevent testicular necrosis. While surgical exploration and orchiopexy have traditionally been the primary interventions, manual detorsion has recently gained acceptance as an initial treatment before the surgical exploration (1-3). Success rate of the detorsion varies across studies, ranging from 26% to 86% (1,2,4-6). Orchiopexy is usually recommended after the detorsion, but without specific timing to perform it. Only a few cases have been reported on the recurrence of testicular torsion following the detorsion without subsequent surgical exploration and orchiopexy (6,7). The aim of this study was to assess the recurrence rate of testicular torsion in patients who underwent successful detorsion but did not undergo orchiopexy within 24 hours.

This retrospective study was approved with a waiver for informed consent by the ethics committee of Saitama Children’s Medical Center and conducted in accordance with the tenets of the Declaration of Helsinki (IRB no. 2024-04-002).

A review of medical records from September 2017 through September 2024 identified 38 pediatric patients with testicular torsion who underwent manual detorsion in the emergency department. The following patients were excluded (2): those in whom detorsion was unsuccessful and urgent surgical exploration was required (n = 2); who did not undergo orchiopexy after successful detorsion (n = 1); and who underwent surgical exploration and orchiopexy within 24 hours after the detorsion (n = 8).

The following patient characteristics at first testicular torsion were recorded: patient age at the diagnosis of testicular torsion, laterality (right/left) and direction (medial/lateral) of torsion, hours from the onset to manual detorsion, presence of testicular atrophy, the days from the detorsion to recurrence, and the days from first detorsion to orchiopexy. Testicular atrophy was defined as a decrease in the testicular size (< 80%) when compared with that of the unaffected side (8). The atrophy indicates tissue damage and potential functional impairment, which may affect fertility (9). Testicular size was evaluated via ultrasonography and clinical examination 2-3 months after successful detorsion. As for an outcome variable, we recorded the presence of recurrence of torsion before orchiopexy.

Once testicular torsion was diagnosed, manual detorsion was routinely attempted by pediatric surgeons or urologists, without providing sedation or analgesia in order to evaluate pain relief. The pediatric surgeons or urologists rotated the affected testis based on sonographic findings, typically following the “open book” direction; clockwise for the right testis and counterclockwise for the left. The procedure was occasionally repeated 1-2 times to ensure adequate revascularization of the entire testis, diminish the whirlpool sign associated with the twisted spermatic cord, and achieve pain relief. Its success was determined by pediatric surgeons, radiologists, or emergency physicians based on the following criteria: complete pain relief, restoration of vascular flow within the testis, and disappearance of the whirlpool sign on a Doppler sonogram (10-13). If any of these findings remained, urgent surgical exploration and orchiopexy were performed.

After successful detorsion, orchiopexy was performed by pediatric urologists or surgeons, with the timing determined based on patient availability and condition. At our institution, patients who experienced successful detorsion with complete pain relief were typically discharged, returned for a follow-up visit, and then scheduled for orchiopexy. As a result, the interval between successful detorsion and orchiopexy varied for each patient.

As for statistical analysis, data are presented as medians with interquartile ranges. The patients’ characteristics in the first testicular torsion were compared between those with and without recurrence using the Fisher’s exact tests or Mann-Whitney U-tests. The significance level for all tests was set at a P < 0.05 (2-sided). All analyses were performed using IBM SPSS ver. 24 (IBM Corp.).

We analyzed 27 patients with testicular torsion who underwent successful detorsion without urgent surgical exploration or orchiopexy (Table). Three of the 27 patients (11.1%) experienced the recurrences 35, 80, and 340 days after the detorsions, respectively. Two of the 3 patients underwent left-sided cases while all did medially twisted cases. One patient developed a recurrence on the right testis at day 35, which was contralateral to the affected side in the initial episode. The other 2 patients showed consistent patterns of the laterality and direction of their recurrences.

Table.

Patients’ characteristics of the first testicular torsion

In the 24 cases without recurrences, the median value of the days from manual detorsion to orchiopexy was 26 days (interquartile range, 15.5-41.5) after the detorsions. There were no significant differences according to the presence of recurrences, age, laterality, and direction of torsion, or presence of testicular atrophy (Table).

In this current study, the recurrences of testicular torsion after successful detorsions before orchiopexy occurred in 3 of the 27 patients, at a timing ranging from 35 to 340 days after the detorsions. To prevent such recurrences, orchiopexy should be timely performed after manual detorsion. In our limited cohort, no recurrences on the same side occurred during the acute phase after the detorsions. Immediately after the detorsion, the spermatic cord typically appears edematous and a pseudo-mass lesion (10,16). This tissue edema leads to a loss of tissue elasticity, which can result in restricted movement (17). Therefore, the edematous change may help prevent an immediate recurrence resulting from free movement of the cord or testis. However, once the edema resolves, the risk of recurrence remains for a prolonged period. The exact timeline for the resolution of the spermatic cord edema may vary depending on the degree of torsion. As per our limited findings, if a detorsion is successful, elective orchiopexy, not immediately after the detorsion, is an appropriate approach.

In conclusion, while a recurrence of testicular torsion after manual detorsion is not uncommon, a recurrence may typically occur in a matter of months. Since the risk persists over time, orchiopexy should be timely performed.