BJU International (1999), 83, 672–674

Manual derotation of the twisted spermatic cordE.B. CORNEL and H.F.M. KARTHAUSDepartment of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands

Objective To re-emphasize the safety and eBcacy of of all symptoms and normal findings at physicalexamination. No testicular atrophy was detectedmanual derotation in the management of the twisted

spermatic cord. during the follow-up (mean 22 months, range 9–72).Conclusions These results reinforce the eBcacy andPatients and methods Seventeen patients (mean age 15

years, range 13–28) with acute unilateral torsion of safety of manual derotation with subsequent electivebilateral orchidopexy as the primary treatment for thethe spermatic cord, initially treated by manual detor-

sion, were reviewed; all 17 patients were seen by one twisted spermatic cord.Keywords Testicular torsion, therapy, manualconsulting urologist (H.F.M.K.).

Results In 14 of the 17 patients the attempt resulted in derotationsuccessful manual derotation, i.e. the immediate relief

painful testicle was palpated, together with a thickenedIntroduction

spermatic cord. The cremasteric reflex was absent inmost cases. As neither Doppler flow ultrasonography norTorsion of the spermatic cord is a urological emergency,

with early diagnosis and derotation of vital importance radionuclide scanning can exclude torsion, thesemethods were not used in the diagnosis.in preventing ischaemic damage. Most testes are salvaged

if the normal blood supply is restored within 6 h [1,2]. Manual derotation, as described by Workman andKogan [4] was attempted in 17 patients (28%) and theIn 1893, Nash [3] described successful manipulative

reduction of the twisted spermatic cord as an alternative other 44 underwent emergency surgical scrotal explo-ration. All manual derotation procedures were performedto emergency surgical exploration. Since 1966, 15

diCerent groups have described the eBcacy and safety of or supervised by one of the three urologists (H.F.M.K.),whereas the other 44 patients were seen by the twothis procedure in case reports or small series.

Nevertheless, the last report was published in 1988 by other consulting urologists. As most testes are twistedinwards, initial derotation was attempted outwards [5].Workman and Kogan [4]. Surgical exploration and sub-

sequent derotation and orchidopexy or orchidectomy, If the pain increased and/or there was resistance, theopposite rotation was attempted. Successful manualdepending on the viability of the organ, remains the

gold standard. In view of the safety, eBcacy and speed derotation was defined as the immediate relief of allsymptoms, normal findings at physical examination andof the procedure, we reviewed our experience and

re-emphasize the importance of this treatment in the no evidence of testicular atrophy during follow-up. Thesecriteria not only defined a successful procedure but alsomanagement of the twisted spermatic cord.confirmed the diagnosis. Symptoms and signs of epidi-dymo-orchitis or torsion of a hydatid of Morgagni do not

Patients and methodsresolve on manual derotation. Local anaesthesia was notgiven because this eliminated the relief of pain as anBetween January 1991 and December 1996, 61 patients

with a clinical diagnosis of unilateral torsion of the important indicator of successful detorsion. After manualderotation all patients underwent elective bilateral scro-spermatic cord were referred to our teaching hospital.

The diagnosis was based on a history and physical tal orchidopexy. Patient information was obtained at theinitial hospitalization, during follow-up visits, by tele-examination; history revealed acute hemiscrotal pain

with in most cases one or more previous episodes of less phone and through the referring physician.severe scrotal pain. Nausea and vomiting were commonsymptoms but no patient had urinary symptoms or fever.

ResultsOn physical examination a high and transverse-lying

Manual derotation was initially attempted in 17 patientswith a clinical diagnosis of torsion of the spermatic cordAccepted for publication 24 November 1998

672 © 1999 BJU International

MANUAL DEROTATION OF THE TWISTED SPERMATIC CORD 673

Table 1 Manual detorsion of the twisted spermatic cord; literature scrotal orchidopexy in any of the 14 successful manualreview and case series derotations. These results are comparable with others

(Table 1) [6–8,10].No. of Primary

The present results emphasize that manual derotationReference patients MD* Success Salvage

is a noninvasive, quick and safe method leading to thedesired result, i.e. eCective derotation of the twisted[8] 206 16 11 ?spermatic cord and salvage of the involved testis.[10] 19 8 5 5

[6] 16 16 15 14 Nevertheless, manual detorsion is currently seldom used[7] 104 34 34 34 by urologists or emergency-ward doctors. Surgical

exploration followed by derotation, bilateral orchidopexy*Patients who underwent a primary attempt at manual detorsion. or orchidectomy, the latter depending on the viability

of the organ, is still the ‘gold standard’. There areseveral explanations why this manoeuvre is so unpopu-(mean age 15 years, range 13–28). The mean (range)

time from the onset of symptoms to diagnosis was 4 lar. First, a twisted testis can be extremely painful andthus unapproachable. It is therefore not surprising that(1–24) h; two patients had had symptoms for >6 h (15

and 24 h). The torsion was on the right side in nine due to pain and oedema, three of 17 attempts failed.This problem can be overcome in some patients whenpatients and on the left in eight. To relieve torsion,

manual derotation of 180–540° was suBcient and this the manoeuvre and its advantages are explained clearlyto the patient. Second, an orchidopexy is performed inwas performed within 5 min.

In three of the 17 patients manual derotation was all cases anyway and therefore many doctors find thismanoeuvre bothersome. However, torsion of the sper-discontinued because it was too painful and oedema of

the scrotum precluded approaching the twisted testis. At matic cord is a urological emergency and it is importantto prevent ischaemic damage of the testis by minimisingemergency surgical exploration these three testis were

viable after derotation and a bilateral orchidopexy was the duration of ischaemia. After manual derotation,blood flow is immediately restored. Moreover, afterperformed.

Bilateral scrotal orchidopexy was performed in all successful noninvasive manual derotation this uro-logical emergency now becomes an elective orchido-cases of successful manual derotation. The time elapsed

between successful manual derotation and bilateral scro- pexy. Third, many doctors are not familiar with theprocedure; in our teaching hospital, only one of thetal orchidopexy varied from 2 h to 3 months (mean

12 h). At orchidopexy, all untwisted testes appeared three urologists performs it and thus only 17 of the 61patients diagnosed with torsion of the spermatic cordviable and during the follow-up (9–72 months, mean

22) after a scrotal orchidopexy, all untwisted testes underwent the procedure. Thus manual detorsion is thetreatment of first choice for this urological emergency,remained normal with no evidence of atrophy.being quick, noninvasive, eBcient and safe.

DiscussionReferences

Manual derotation of the twisted testis is an old concept;1 Allen WR, Brown RB. Torsion of the testis: a review of 58

in 1893, Nash [3] described this procedure and since cases. Br Med J 1966; 1: 1396then several investigators have described the success of 2 Skogland RW, McRoberts JW, Ragde H. Torsion of thethis noninvasive manoeuvre [3,5–9]. However, since spermatic cord: a review of the literature and an analysis1966, only four series have been published with a total of 70 new cases. J Urol 1970; 104: 604

3 Nash WG. Acute torsion of the spermatic cord: reduction:of 74 patients (Table 1). In 65 of 74 patients (87%) theimmediate relief. Br Med J 1893; 1: 742initial attempt ended in a successful manual derotation

4 Workman SJ, Kogan BA. Old and new aspects of testicular[6–8,10]. Most importantly, in 64 of 65 successfultorsion. Semin Urol 1988; 6: 146–57derotations (98%), as defined by immediate relief of all

5 Ransler CW, Allen TD. Torsion of the spermatic cord. Urolsymptoms and normal findings at physical examination,Clin North Am 1982; 9: 245–50the testes were salvaged, as judged during orchidopexy

6 Kiesling VJ, Schroeder DE, Pauljev P, Hull J. Spermaticand on follow-up [6–8,10].

cord block and manual reduction: primary treatment forIn the present series, all testes were saved after spermatic cord torsion. J Urol 1984; 132: 921–3

manual derotation; 14 of 17 attempts at manual 7 Catolica EV. Preoperative manual detorsion of the torsedderotation were successful, as judged by the criteria spermatic cord. J Urol 1985; 133: 803–5used. Retorsion of the derotated testis did not occur 8 Lee LM, Wright JE, McLoughlin MG. Testicular torsion in

the adult. J Urol 1983; 130: 93–4between the time of manual derotation and elective

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674 E.B. CORNEL and H.F.M. KARTHAUS

9 Frazier WJ, Bucy JG. Manipulation of torsion of the testicle. AuthorsJ Urol 1975; 114: 410–1 E.B. Cornel, MD, PhD, Resident in Urology.

10 Vordermark JS. Testicular torsion: management with H.F.M. Karthaus, MD, PhD, Consultant.ultrasonic doppler flow detector. Urology 1984; 14: 41–2 Correspondence: Dr E.B. Cornel, Department of Urology,

Academic Hospital Nijmegen, PO Box 9101, 6500 HBNijmegen, The Netherlands.

© 1999 BJU International 83, 672–674