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Manual Testicular Detorsion by Emergency Clinicians
Andrew Wofford, MD1, D. Preston Smith, MD2, Dante Pappano, MD3, Rhys Irvine, MD4, Jacqueline Morin, MD4.
1University of Tennessee Medical Center, Knoxville, TN, USA, 2University Pediatric Urology, Knoxville, TN, USA, 3Children's Pediatric Group Emergency Department, Knoxville, TN, USA, 4Dolly Parton Children's Hospital Urology, Knoxville, TN, USA.
Background:Manual testicular detorsion (MTD) has been shown to improve testicular salvage in the setting of acute testicular torsion. In 2020, our urology providers educated and encouraged MTD by our emergency clinicians at our children’s hospital. We sought to evaluate outcomes following the introduction of this new clinical pathway at our institution.
Methods:Retrospective review was performed on 120 patients aged 0.8-19.7 years who presented to a single pediatric hospital with the diagnosis of testicular torsion between 01/31/2021 and 08/15/2025. Data was collected and analyzed regarding age and timing of presentation, attempt and success rates of MTD, periprocedural analgesia, operative timing, intraoperative findings, and testicular viability.
Results:Overall, 74.2% (n=89/120) of patients underwent an attempted MTD. Of these, 89.9% (n=80/89) were performed by an emergency clinician. MTD was successful in 58.4% (n=52/89), as defined by improvement of pain and restoration of testicular blood flow on doppler ultrasonography. Of the 52 successful MTD, emergency clinicians performed 88.5% (n=46/52). In only 3 patients (5.8%), a urologist succeeded when an emergency clinician failed MTD.
Median time of symptom onset to presentation was 3.5 hours in those with successful MTD and 10.0 hours with unsuccessful MTD attempt (p=<0.001). Periprocedural narcotic (n=53) or sedation (n=4) was used in 64.0% of MTD attempts and did not improve success rate (p=0.23).
Median time from presentation to operative intervention (OR) was 3.3 hours (IQR 2.4-8.8) following unsuccessful MTD attempt and 3.9 hours (IQR 2.4-16.2) without attempted MTD. Following successful MTD, time to OR was extended to a median of 12.8 hours (IQR 5.8-22.8, range 2 hours-46 days), with 23.1% (n=12/52) presenting to OR >24 hours.
There was a 29.2% overall orchiectomy rate (n=35/120). Orchiectomy was performed in 0% (n=0/52) of successful MTD patients, 43.2% (n=16/37) of unsuccessful attempted MTD patients, and 61.3% (n=19/31) of patients without attempted MTD. Only 7.7% (n=4) of patients were found to have partial torsion intraoperatively following successful MTD and none of these required orchiectomy or experienced testicular atrophy at follow-up.
There was a 71.7% overall follow-up rate (n=86/120) with a median interval of 49.5 days (IQR 36-106). Of the patients who underwent testicular fixation and followed up, 87.7% (n=50/57) had testicular viability without atrophy. Of these testicular fixation patients, those with successful MTD had 96.9% (n=31/32) viability without atrophy compared to only 76.0% (n=19/25) of those without successful MTD (p=0.036).
Conclusions:Our study has reaffirmed that MTD reduces ischemia time and orchiectomy rates, while improving testicular viability at follow-up. We have shown that emergency clinicians can successfully perform MTD and improve overall outcomes. Delaying time to OR for elective testicular fixation was also shown to be safe in patients who underwent successful MTD. Although not specifically evaluated in this study, non-emergent elective fixation should lower anesthesia risks, overall costs, and emergent transfer from underserved areas for urologic care. Emergency clinicians’ training programs should incorporate MTD in their curriculum as the standard of care for those with acute testicular torsion.
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