Delayed Emergency Management of Testicular Torsion in a Rural Hospital Without Urologist: A Case Report
Keywords:
testicular torsion, TWIST score, rural hospital, orchiectomy, emergency delayAbstract
BackgroundTesticular torsion is a time-sensitive urological emergency requiring prompt diagnosis and surgical intervention to prevent irreversible ischemia and testicular loss. International guidelines emphasize immediate surgical exploration in patients with high clinical suspicion rather than delaying intervention for confirmatory imaging. Delays are more common in rural hospitals due to limited resources and lack of urologists.
Case PresentationA 13-year-old boy presented with sudden severe left scrotal pain. Physical examination revealed a hard, horizontally lying left testis with absent cremasteric reflex. The TWIST score was 6, indicating high risk of torsion. Color Doppler ultrasonography showed reduced perfusion. Surgical exploration was performed approximately 7 hours after admission, revealing intravaginal torsion exceeding 360° with non-viable testis. Left orchiectomy and right orchidopexy were performed. Postoperative recovery was uneventful.
DiscussionThis case highlights the importance of early clinical diagnosis, utilization of the TWIST score, and prompt surgical management. Delayed intervention related to emergency department workload, operating room availability, and absence of on-site urologists contributed to testicular loss.
ConclusionIn rural hospitals without urologists, standardized triage using TWIST, early surgical referral, and consideration of manual detorsion are essential to reduce preventable orchiectomy.
References
Laher A, Ragavan S, Mehta P, Adam A. Testicular torsion in the emergency room: a review of detection and management strategies. Open Access Emergency Medicine. 2020;12:237–246. doi:10.2147/OAEM.S233967
European Association of Urology. EAU Guidelines on Paediatric Urology. Arnhem: EAU Guidelines Office; 2023. Available from: https://uroweb.org/guidelines/paediatric-urology
Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. American Family Physician. 2013;88(12):835–840.
Mellick LB, Sinex JE, Gibson RW, Mears K. A systematic review of testicle survival time after a torsion event. Pediatric Emergency Care. 2019;35(12):821–825. doi:10.1097/PEC.0000000000001238
American Urological Association. Management of Acute Scrotum: Clinical Guideline. Baltimore: American Urological Association; 2022. Available from: https://www.auanet.org/guidelines
Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. Journal of Urology. 2013;189(5):1859–1864. doi:10.1016/j.juro.2012.10.056
Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG, et al. Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score. Journal of Urology. 2016;195(6):1870–1876. doi:10.1016/j.juro.2016.01.101
Fehér ÁM, Bajory Z. A review of main controversial aspects of acute testicular torsion. Journal of Acute Disease. 2016;5(1):1–8. doi:10.1016/j.joad.2015.06.017
Ellati RT, Kavoussi PK, Turner TT, Lysiak JJ. Twist and shout: a clinical and experimental review of testicular torsion. Korean Journal of Urology. 2009;50(12):1159–1167. doi:10.4111/kju.2009.50.12.1159
Srinivasan A, Cinman N, Feber KM, Gitlin J, Palmer LS. History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff. Journal of Pediatric Urology. 2011;7(4):470–474. doi:10.1016/j.jpurol.2010.12.010
Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatric Radiology. 2018;48(5):735–744. doi:10.1007/s00247-018-4093-0
McDowall J, Adam A, Gerber L, et al. The ultrasonographic “whirlpool sign” in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis. Emergency Radiology. 2018;25(4):395–403. doi:10.1007/s10140-018-1579-x
Anderson JB, Williamson RCN. Testicular torsion in Bristol: a 25-year review. British Journal of Surgery. 1988;75(10):988–992. doi:10.1002/bjs.1800751015
Cornel K. Manual derotation of the twisted spermatic cord. BJU International. 2001;87(6):672–674. doi:10.1046/j.1464-410x.2001.02135.x
Demirbas A, Demir DO, Ersoy E, Kabar M, Oguz A, Yilmaz M. Should manual detorsion be a routine part of treatment in testicular torsion? BMC Urology. 2017;17(1):84. doi:10.1186/s12894-017-0276-5
Matteson JR, Stock JA, Hanna MK, Arnold TV, Nagler HM. Medicolegal aspects of testicular torsion. Urology. 2001;57(4):783–786. doi:10.1016/S0090-4295(00)01049-9
Arap MA, Vicentini FC, Cocuzza M, Hallak J, Athayde KS, Srougi M. Late hormonal levels, semen parameters, and presence of antisperm antibodies in patients treated for testicular torsion. Journal of Andrology. 2007;28(4):528–532. doi:10.2164/jandrol.106.002097
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Satrio Budi Wicaksono , Yustina (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
