- Clinical science
Testicular torsion is the sudden twisting of the spermatic cord within the scrotum. It most commonly affects neonates and young men. Because of the risk of ischemia and possible infarction of the testis, it is considered a urological emergency. Testicular torsion is characterized by sudden-onset unilateral testicular pain, which may radiate to the lower abdomen, with nausea and vomiting. Clinical findings include a high-riding testis with an absent cremasteric reflex. Imaging with duplex ultrasound of the scrotum may be required if the clinical diagnosis is in doubt. If testicular torsion is suspected, prompt surgical exploration within six hours of symptom onset is essential to salvage the testis. Important differential diagnoses, e.g., orchitis and epididymitis, should be ruled out before initiating treatment.
- Testicular torsion involves a sudden twisting of the spermatic cord associated with a poorly secured testicle.
- Torsion result in venous engorgement with consequent arterial compromise, tissue ischemia, and possible infarction. Irreversible damage occurs after approx. 6–12 hours of torsion.
Abrupt onset testicular pain and/or pain in the lower abdomen
- Typically swollen and tender testicle and/or lower abdominal tenderness
- Nausea and vomiting
Abnormal position of testicle
- Abnormal transverse lie
- Scrotal elevation
- Possible undescended testes (predisposes to testicular torsion)
- Absent cremasteric reflex
- Prehn sign: negative
Testicular torsion should always be suspected in a male patient with severe, sudden-onset testicular pain!
Testicular torsion is typically a clinical diagnosis. Imaging is not routinely indicated but may be considered in patients with atypical clinical features. Because of the significant risk of infertility, diagnostic workup should not delay the management of suspected testicular torsion.
- Duplex ultrasound of the scrotum 
Radionuclide imaging 
- Inconclusive clinical findings
- Evaluate for epididymitis
- Characteristic findings
Surgical intervention is recommended for suspected testicular torsion, regardless of radiological findings.
|Differential diagnosis of scrotal pain|
|Testicular torsion|| |
|Testicular tumor|| |
|Torsion of testicular appendage (hydatid of Morgagni)|| || |
- Description: The hydatid of Morgagni (appendix of the testes) is an embryological remnant on the upper pole of the testes or at the epididymis (the remnant of the Müllerian duct). This hydatid of Morgagni has the potential to rotate. The resultant symptoms resemble acute testicular torsion.
- Typically boys 3–5 years old
- Insidious unilateral scrotal tenderness
- "Blue dot sign"
- Imaging: doppler ultrasound may show an enlarged testicular appendix and or mild hydrocele with preserved testicular blood flow
- Management: A conservative approach with NSAIDs may be considered. However, if in doubt, surgical intervention is required to examine the testes.
The differential diagnoses listed here are not exhaustive.
Testicular torsion is a medical emergency and should ideally be treated within 6 hours of the onset of symptoms for the best chance of testicular salvage. Manual detorsion in the ER may be attempted prior to surgery for immediate pain relief, but should not delay transferring the patient to the OR.
Exploratory surgery 
- Indication: suspected testicular torsion
- Timing: ideally, within 6 hours of symptom onset 
- Immediate surgical exploration of the scrotum with reduction (untwisting) and of the affected testis
- Orchidopexy of the contralateral testis is recommended because the risk of testicular torsion on the contralateral side increases with previous or current testicular torsion.
- Orchiectomy if the testis is grossly necrotic or nonviable
Manual detorsion 
- Indication: : may be attempted prior to surgery for immediate pain relief or if surgery is not immediately available
- Rotate the testis laterally toward the thigh ; two-thirds of torsions occur toward the midline.
- If lateral rotation does not provide symptom relief, rotate the testis toward the midline; one-third of torsions occur laterally. 
- Surgery should still be performed in all patients to resolve any possible degree of remaining torsion and to prevent recurrence.