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M2E Too!: The torso testicle traction technique : Emergency Medicine News

testicular torsion, manual detorsion:

Manual traction down the left testicle followed by external rotation to unwind the twisted spermatic cord.

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Should immediate attempts at manual reduction of testicular torsion be the standard of care? Undoubtedly, the timely manual untwisting of a twisted testicle saves the organ from death. (Pediatric emergency care. 2019;35[12]:821; Pediatric emergency care. 2012;28[1]:80; https://bit.ly/3T9W0N0.)

The untwisting procedure is sometimes quick and easy, but other times it is technically difficult and even unsuccessful. Unfortunately, many doctors are hesitant to attempt manual detorsion because they lack confidence in the procedure or fear making the twist worse.

Testicles twisted for a prolonged period will also have swelling and edema which, along with other mechanical factors, increase the difficulty of these rotational maneuvers. I previously described a maneuver involving downward traction of the twisted testicle that could potentially increase the success rate of the procedure. (May 2, 2022; https://bit.ly/3pCxaIa.)

I can now report that I have successfully performed the maneuver on several patients and named it the Torso Testicle Traction technique. This newly recognized technique was recently published (Pediatric emergency care. 2022 Aug 16. doi: 10.1097/PEC.0000000000002827) and is demonstrated with a model in a video from my blog: bit.ly/EMNMellick. The testicular torsion traction technique may be a primary manual reduction maneuver for any testicular torsion, but it may be more useful as an adjunct for failed or difficult reductions.

To perform the testicular twisting technique:

  1. Document by ultrasound the twisted spermatic cord and the absence of blood flow to the involved testicle.
  2. Consider controlling pain with intranasal fentanyl or intravenous morphine. Pain medication can be considered optional as the procedure is quick and pain relief is an important indicator of success.
  3. The twisted testicle is grasped with one or both hands and the spermatic cord is stretched to its maximum length. (Be sure to observe if the testicle twists or turns during or after the stretching procedure.)
  4. Perform manual testicular detorsion procedure by external rotation (right testicle counterclockwise, left testicle clockwise [the open book technique]) until the spermatic cord appears normal. Resistance usually indicates that the reduction maneuver was in the wrong direction.
  5. Ultrasound of the testicle and spermatic cord should then confirm the return of blood flow and the absence of signs of vortex or torsion.

The spermatic cord and attached testis are highly mobile and retractable, and the testis and spermatic cord under normal conditions can be protectively stretched or retracted by the cremaster muscle in response to cold and flight or fear. (Clin Neurophysiol. 2020;131[6]:1354; StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Jan 2022; https://bit.ly/3QVTBUg.) Therefore, this stretching maneuver should be physiologically well tolerated.

The twisted spermatic cord becomes edematous, enlarged, and sometimes incarcerated if the twist is prolonged. Removing a twisted, swollen, and incarcerated spermatic cord away from the inguinal canal increases the success of the procedure. It is important to note that stretching the spermatic cord does not appear to guarantee spontaneous disentangling of the twisted cord, and attempts at manual reduction should always follow. The opportunity to increase blood flow should improve with stretching alone, even if spontaneous resolution does not occur.

This new technique has the potential to increase the practitioner’s confidence in performing the manual reduction procedure for testicular torsion. It can be used as a first step in manual reduction or as a useful adjunct when attempts to reduce testicular torsion have failed. Remember the essential role of ultrasound in documenting improved blood flow to the testicle and an uncoiled spermatic cord.

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Dr. Mellickis professor of emergency medicine, vice president of academic affairs in emergency medicine, section chief of pediatric emergency medicine, and associate director of the residency program at the University of South Alabama in Mobile. Read his monthly blog athttp://bit.ly/EMN-Mellick, and follow him on Twitter@Lmellick.