Testicular Torsion

A 21-year-old man presents to the emergency department with sudden-onset severe testicular pain that began 6 hours ago while playing basketball. The pain is acute, severe, and localized to the right testis. He also reports nausea. On examination, the right hemiscrotum is swollen, erythematous, and tender. The cremasteric reflex is absent. The affected testis appears high-riding with a horizontal lie. Vital signs show a blood pressure of 110/80 mm Hg, pulse rate of 88 beats/min, respiratory rate of 16 breaths/min, temperature of 96.7 °F, and oxygen saturation of 98% on room air. Color Doppler ultrasonography demonstrates absent blood flow to the right testis. Diagnosis?

Diagnosis is Testicular torsion.

1. Definition

Testicular torsion is a urological emergency caused by twisting of the spermatic cord, resulting in impaired testicular blood flow and progressive ischemia.

Without prompt restoration of perfusion, prolonged ischemia can lead to testicular infarction, necrosis, and loss of the affected testis.

2. Etiology and Predisposing Factors

1.      The most important anatomical predisposition in adolescents and adults is the bell-clapper deformity.

2.      In this anomaly, the testis lacks normal posterior fixation within the scrotum because the tunica vaginalis has an abnormally high attachment around the spermatic cord.

3.      This increased mobility allows the testis to rotate freely within the tunica vaginalis and twist the spermatic cord.

4.      The bell-clapper deformity is frequently bilateral, which explains the need for fixation of the contralateral testis during surgery.

5.      The affected testis may assume a horizontal or transverse lie.

6.      Torsion may occur spontaneously, during sleep, or in association with physical activity or minor trauma, but an identifiable trigger is not required.

3. Pathophysiology

1.      Rotation of the testis causes twisting of the spermatic cord.

2.      Venous and lymphatic outflow are usually compromised first because these vessels are more easily compressed.

3.      Progressive venous congestion leads to testicular edema and increased intratesticular pressure.

4.      Continued torsion eventually compromises arterial inflow.

5.      Reduced arterial perfusion produces testicular ischemia.

6.      Persistent ischemia can progress to hemorrhagic infarction and testicular necrosis.

7.      The extent of injury depends primarily on the duration and degree of spermatic cord torsion.

4. Clinical Features

4.1 Typical Presentation

1.      Sudden-onset severe unilateral testicular or scrotal pain

2.      Scrotal tenderness

3.      Scrotal swelling

4.      Scrotal erythema, particularly as ischemia progresses

5.      Nausea and vomiting

6.      Pain may occasionally radiate to the lower abdomen or groin

4.2 Characteristic Examination Findings

1.      Absent or diminished cremasteric reflex on the affected side

2.      High-riding testis

3.      Horizontal or transverse lie of the testis

4.      Marked testicular and scrotal tenderness

5.      Progressive scrotal edema and erythema

An absent cremasteric reflex is strongly suggestive of testicular torsion in the appropriate clinical setting, but no single physical examination finding can independently confirm or exclude the diagnosis.

5. Diagnostic Evaluation

5.1 Clinical Diagnosis

1.      Testicular torsion should be strongly suspected in a young man with abrupt severe unilateral testicular pain, nausea or vomiting, a high-riding or horizontally oriented testis, and an absent cremasteric reflex.

2.      It is primarily a clinical and time-critical diagnosis.

3.      When clinical suspicion is high, urgent urological consultation and surgical exploration should not be delayed to obtain imaging.

4.      Diagnostic testing should be used when the diagnosis is uncertain and when it can be obtained without delaying definitive treatment.

5.2 Color Doppler Ultrasonography

1.      Color Doppler ultrasonography is the principal imaging modality when imaging is required.

2.      The characteristic finding is reduced or absent intratesticular blood flow compared with the contralateral testis.

3.      Additional findings may include testicular enlargement, heterogeneous echotexture, scrotal wall thickening, and twisting of the spermatic cord.

4.      The whirlpool sign, representing a twisted spermatic cord, is a highly suggestive sonographic finding.

5.      Preserved blood flow does not completely exclude torsion, particularly in partial, early, or intermittent torsion.

6.      If the clinical presentation remains highly suspicious despite equivocal imaging, surgical exploration is warranted.

6. Management

6.1 Emergency Surgical Management

1.      Immediate surgical exploration and detorsion are the definitive management.

2.      The spermatic cord is untwisted and the affected testis is assessed for viability.

3.      If the testis is viable, orchiopexy of the affected testis is performed to prevent recurrent torsion.

4.      The contralateral testis is also fixed, usually during the same operation, because the underlying anatomical predisposition is commonly bilateral.

6.2 Time Sensitivity

1.      Testicular salvage is most likely when detorsion occurs within approximately 4 to 6 hours after symptom onset.

2.      The probability of salvage decreases progressively as the duration of ischemia increases, particularly after 6 to 12 hours.

3.      There is no absolute time point at which a testis can be assumed to be nonviable because viability also depends on the degree of torsion and individual vascular factors.

4.      Surgical exploration remains indicated even with delayed presentation because symptom duration alone cannot reliably determine testicular viability.

6.3 Manual Detorsion

1.      Manual detorsion may be attempted as a temporary maneuver while urgent surgical management is being arranged.

2.      Manual detorsion is a temporizing maneuver and does not replace urgent surgical exploration and orchiopexy.

3.      It should be attempted only when it does not delay definitive surgery.

4.      The testis is commonly rotated outward, often described as an open-book maneuver, although the direction of torsion can vary.

5.      If pain increases or resistance is encountered, rotation in the opposite direction may be necessary.

6.      More than one rotation may be required because the spermatic cord can twist through multiple turns.

7.      Successful detorsion is suggested by rapid pain relief, normalization of testicular position, and restoration of blood flow on Doppler ultrasonography.

8.      Residual torsion may remain despite clinical improvement, so surgical exploration and definitive fixation are still required.

6.4 Nonviable Testis

1.      If the affected testis is clearly nonviable despite detorsion and reassessment, orchiectomy is performed.

2.      Contralateral orchiopexy is performed to prevent subsequent torsion of the remaining testis.

7. Complications

7.1 Testicular Infarction and Necrosis

Prolonged interruption of blood flow can cause irreversible ischemic injury, resulting in testicular infarction and necrosis.

7.2 Testicular Atrophy

Even a testis that appears viable at surgery may subsequently undergo testicular atrophy because of prior ischemic injury.

7.3 Loss of the Testis

Severe or prolonged torsion may require orchiectomy if the affected testis is nonviable.

7.4 Impaired Fertility

Testicular torsion may be associated with abnormalities in spermatogenesis and semen parameters. The effect on long-term fertility varies according to the severity of injury, testicular salvage, function of the contralateral testis, and other individual factors.

7.5 Recurrent Torsion

Inadequate fixation or failure to perform orchiopexy may permit recurrent torsion, although recurrence after appropriate fixation is uncommon.

8. Key Clinical Insight

Sudden severe unilateral testicular pain with nausea, an absent cremasteric reflex, a high-riding horizontally oriented testis, and absent or markedly reduced blood flow on Doppler ultrasonography is highly characteristic of testicular torsion.

Testicular torsion is a time-critical surgical emergency. When clinical suspicion is high, definitive surgical management should not be delayed for additional diagnostic testing.

References

1.      Laher A, Ragavan S, Mehta P, Adam A. Testicular torsion in the emergency room: a review of detection and management strategies. Open Access Emerg Med. 2020;12:237-246. doi:10.2147/OAEM.S236767.

2.      Moore SL, Chebbout R, Cumberbatch M, et al. Orchidopexy for testicular torsion: a systematic review of surgical technique. Eur Urol Focus. 2021;7(6):1493-1503. doi:10.1016/j.euf.2020.07.006.

3.      European Association of Urology. EAU Guidelines on Paediatric Urology. In: EAU Guidelines. Arnhem, The Netherlands: EAU Guidelines Office; 2026.