Testicular Torsion Treatment in Singapore

• Sudden onset of severe testicular pain, often waking patients from sleep
• Testicular swelling and scrotal redness on the affected side
• Abnormal testicular position (higher than normal or horizontal lie)
• Nausea and vomiting accompanying testicular pain
• Absent cremasteric reflex (testicle doesn’t rise when inner thigh is stroked)
• Previous episodes of intermittent testicular pain that resolved spontaneously
• Bell-clapper deformity detected on examination or imaging

• Neonates with prenatal or perinatal torsion requiring urgent evaluation
• Adolescent males (peak incidence age 12-18) with acute scrotal pain
• Adult males with sudden testicular pain, regardless of age
• Patients with history of undescended testicle (cryptorchidism)
• Those with familial history of testicular torsion

• Torsion of testicular appendix (less urgent but may need treatment)
• Epididymitis or orchitis (inflammatory conditions)
• Trauma-related testicular injury
• Incarcerated inguinal hernia
• Idiopathic scrotal oedema

Immediate surgical consultation with a urologist is essential when testicular torsion is suspected. Clinical examination combined with colour Doppler ultrasound helps confirm diagnosis, though surgery should not be delayed if clinical suspicion is high.

Manual detorsion may be attempted in the emergency department as a temporising measure while preparing for surgery. This involves rotating the affected testicle outward (like opening a book) to restore blood flow. While successful in some cases, this technique provides temporary relief and surgery remains necessary to prevent recurrence. Pain relief during manipulation often indicates successful detorsion, though surgical exploration and fixation are still required.

The definitive treatment involves surgical exploration through a scrotal or inguinal incision. The surgeon untwists the spermatic cord, assesses testicular viability, and performs bilateral orchiopexy. During orchiopexy, both testicles are secured to the scrotal wall using non-absorbable sutures in multiple points, preventing future rotation. This bilateral approach is crucial as the anatomical abnormality that allows torsion typically affects both sides.

If the testicle appears non-viable after detorsion – showing no improvement in colour or bleeding after warm compress application – orchiectomy (testicle removal) becomes necessary. This decision considers factors including duration of torsion, degree of rotation, and intraoperative findings. The contralateral testicle still undergoes orchiopexy to prevent future torsion.

Modern surgical management utilises colour Doppler ultrasound for diagnosis when time permits, showing absent or reduced blood flow in torsion. Surgical loupes provide magnification for precise suture placement during orchiopexy. Some centres employ near-infrared spectroscopy to assess tissue oxygenation intraoperatively, helping determine testicular viability.

Upon arrival at the emergency department, immediate assessment includes vital signs, pain evaluation, and scrotal examination. Blood tests check for infection markers and prepare for surgery. Intravenous access is established for fluid administration and pain relief. Colour Doppler ultrasound may be performed if immediately available, but surgery proceeds based on clinical suspicion without waiting for imaging if torsion is strongly suspected.

The surgical team is mobilised urgently, with the operating theatre prepared for emergency surgery. Informed consent covers the surgical procedure, potential for orchiectomy if the testicle is non-viable, and bilateral orchiopexy. Fasting status is assessed, though emergency surgery proceeds regardless due to the time-critical nature.

The procedure begins with general or spinal anaesthesia administration. A midline scrotal incision or bilateral scrotal incisions provide access to both testicles. The affected testicle is delivered through the incision, and the spermatic cord is carefully untwisted. The surgeon notes the degree of rotation (typically 360-720 degrees) and direction.

After detorsion, the testicle is wrapped in warm saline-soaked gauze for 10-15 minutes while observing for colour improvement and bleeding at incision sites. Viable testicles show improved colour and bleeding, indicating restored circulation. The testicle is then secured to the scrotal wall at three points using non-absorbable sutures through the tunica albuginea.

The contralateral testicle undergoes prophylactic orchiopexy through a separate incision or the same incision if midline approach is used. The procedure typically takes 30-60 minutes total.

Following surgery, patients recover in the post-anaesthesia care unit with vital sign monitoring. Ice packs are applied to reduce swelling, and scrotal support is provided. Pain management includes oral analgesics, with stronger medications available if needed. Most patients can be discharged the same day or after overnight observation.

Discharge instructions cover wound care, activity restrictions, and warning signs of complications. Antibiotics may be prescribed prophylactically. Follow-up appointment scheduling ensures proper healing assessment.

Initial recovery focuses on pain control and swelling management. Ice application for 20 minutes every 2-3 hours helps reduce inflammation. Scrotal support with fitted underwear or athletic supporter provides comfort. Pain typically peaks within the first day then gradually improves. Mild bruising and swelling are expected.

Activity should be limited to gentle walking and rest. Straining during bowel movements should be avoided through adequate hydration and stool softeners if needed. Shower permission usually begins after 24 hours, keeping the incision dry. Warning signs requiring immediate medical attention include fever, increasing pain, excessive swelling, or wound drainage.

Gradual activity increase occurs as comfort allows, though heavy lifting and strenuous exercise remain restricted. School or work return is possible within 3-5 days for sedentary activities. Wound inspection ensures proper healing without signs of infection. Dissolvable sutures typically don’t require removal.

Scrotal swelling progressively decreases, though some firmness may persist for several weeks. Bruising colour changes from purple to yellow-green indicate normal healing. Follow-up appointment at one week assesses surgical site healing and testicular position.

Complete healing occurs over 4-6 weeks. Return to sports and vigorous activities is generally permitted after 3-4 weeks, following surgical clearance. Contact sports may require additional protective equipment initially. Sexual activity can resume when comfortable, typically after 2-3 weeks.

Long-term monitoring includes periodic self-examination to ensure testicles remain properly positioned. Annual urological follow-up may be recommended, particularly for younger patients. Fertility assessment might be suggested if testicular atrophy occurs or if orchiectomy was performed.