creation date: 2026-01-19 17:40
tags: Pathologies
Testicular Torsion
Background
Definitions
Testicular torsion refers to the twisting of the testis’ blood supply and spermatic cord.
It is a urologic emergency that is time-dependent with testicular viability significantly decreasing 6 hours after onset of symptoms. Testicular torsion predominantly affect younger patients (<25).
Etiology and Pathogenesis
Usually, testicular torsion occur as a result of a congenital abnormality of the processus vaginalis.
- Tunica vaginalis is too high (bell clapper deformity) which allows a normally immobile spermatic cord to twist inside
- Bilateral in 40% of cases
In neonates, extravaginal torsion may occur as the tunica vaginalis is not adhered.
Malignancy may also result in testicular torsion.
Clinical Presentation
Signs & Symptoms
Scrotal pain:
- Unilateral
- Abrupt onset
- Constant or intermittent
- Not positional
Associated symptoms:
- Nausea/vomiting
- Lower abdominal and inguinal pain
On exam, the testicle may be:
- Abnormal or transverse lie
- In a high position
- Swollen
- Erythematous
- Lack the normal cremasteric reflex (not very reliable)
History & Physical Exam
Immediate physical and history should rule out necrotizing fasciitis which would have signs of:
- Systemic illness
- Hemodynamic instability
- Rapidly progressive erythema and edema of the overlying soft tissues of the scrotum
Risk factors
- Adolescent age (period of growth)
- Congenital abnormality of the tunica vaginalis
Diagnosis
Criteria
Diagnosis of testicular torsion is made with ultrasound (sn: 82, sp: 100). Ultrasound evaluation should be made from the spermatic cord up to the level of the internal ring
Findings include:
- Decreased or absent testicular perfusion
- Twisting of spermatic cord (on high-res US: inhomogeneous mass at inguinal or paratesticular position - Whirlpool sign)
If ultrasound is not available when clinical suspicion is high, urologic consultation and exploratory surgery is indicated.
Note, in the presence of classical findings of torsion, a presumptive diagnosis can be made and surgery consulted immediately.
Work-up
Suspect testicular torsion in cases of severe lower abdominal pain.
Further workup should not come before immediate treatment if ultrasound findings are suggestive of torsion or necrotizing fasciitis.
Further workup for acute scrotal pain is discussed separately.
Differential
In the case of acute scrotal pain, surgical emergencies include:
- Testicular torsion
- Necrotizing fasciitis
The most common cause is acute epididymitis. Other causes include:
- Torsion of appendix testis (non-emergency)
- Trauma
- Postvasectomy pain
- Mumps orchitis
- Testicular cancerIgA vasculitis
- Acute idiopathic scrotal edema
- Acute idiopathic scrotal edema
- Varicocele
- Referred pain
Red Flags / Complications
Complications include:
- Loss of testis
- Infection
- Infertility
- Cosmetic deformity
- Loss or diminished exocrine and endocrine function
Management
Management consist of urologic evaluation and surgery. This consist of:
- Intraoperative detorsion
- Fixation of both testes (to prevent future episodes)
If intraoperative detorsion is not possible within 8 hours, manual detorsion should be attempted while awaiting surgical transfer.