Overview
Testicular Torsion
Topic Overview
Summary
Testicular torsion is a urological emergency caused by twisting of the spermatic cord, compromising blood supply to the testis. Peak incidence is in adolescents but it can occur at any age. The classic presentation is sudden severe unilateral scrotal pain with high-riding testis and absent cremasteric reflex. Urgent surgical exploration is required — do not delay for imaging. The testis can only survive 4-6 hours of ischaemia. Delay leads to testicular loss.
Key Facts
- Emergency: Testis survives only 4-6 hours of ischaemia
- Peak age: 12-18 years (also neonates)
- Clinical diagnosis: Do NOT delay surgery for imaging
- Classic findings: Sudden pain, high-riding testis, absent cremasteric reflex
- Treatment: Emergency surgical exploration + detorsion +/- orchidopexy or orchidectomy
Clinical Pearls
Absent cremasteric reflex is the most sensitive clinical sign
"High-riding horizontal testis" = torsion until proven otherwise
A negative ultrasound does NOT exclude torsion — if clinical suspicion, explore
Why This Matters Clinically
Testicular torsion is time-critical. Every hour of delay reduces testicular salvage rates. A high index of suspicion, clinical diagnosis, and immediate surgical exploration save testes.
Visual Summary
Visual assets to be added:
- Testicular torsion anatomy diagram
- High-riding horizontal testis image
- Bell clapper deformity
- Surgical exploration algorithm
Epidemiology
Incidence
- 1 in 4,000 males under 25 years
- Peak: 12-18 years
- Second peak: Neonatal period
Demographics
- More common in adolescents
- Left testis more commonly affected (longer cord)
- Bilateral torsion rare
Risk Factors
| Factor | Notes |
|---|---|
| Bell clapper deformity | Horizontal lie; inadequate gubernacular attachment |
| Cold weather | Cremasteric contraction |
| Physical activity | Trauma |
| Age 12-18 | Peak incidence |
| Undescended testis |
Pathophysiology
Mechanism
- Spermatic cord twists on its axis
- Occlusion of venous drainage (first) → congestion
- Occlusion of arterial supply → ischaemia
- Testicular infarction if not relieved
Bell Clapper Deformity
- Tunica vaginalis attaches high on cord
- Testis can rotate freely ("clapper in a bell")
- Present bilaterally in most cases
- Reason for bilateral orchidopexy
Time Window
| Duration | Salvage Rate |
|---|---|
| Under 6 hours | Over 90% |
| 6-12 hours | 50% |
| Over 12 hours | Under 10% |
Clinical Presentation
Symptoms
Signs
Negative Prehn's Sign
Red Flags
| Finding | Significance |
|---|---|
| Absent cremasteric reflex | Most sensitive |
| High-riding horizontal testis | Classic |
| Duration under 6 hours | Salvage possible — urgent surgery |
Sudden severe unilateral scrotal pain
Common presentation.
Radiates to lower abdomen
Common presentation.
Nausea and vomiting (common)
Common presentation.
May have history of previous transient episodes
Common presentation.
Clinical Examination
Inspection
- Swelling
- Erythema
- High-riding testis
Palpation
- Horizontal lie
- Extremely tender
- Thickened cord
Cremasteric Reflex
- Stroke inner thigh → normally testis rises
- ABSENT in torsion
Contralateral Testis
- Bell clapper often bilateral
- Will need fixation
Investigations
Clinical Diagnosis
- Torsion is a CLINICAL diagnosis
- Do NOT delay surgery for imaging
Doppler Ultrasound
| Finding | Notes |
|---|---|
| Absent/reduced blood flow | Supports diagnosis |
| Normal flow | Does NOT exclude torsion (intermittent, early) |
| Whirlpool sign | Twisted cord |
Important: If clinical suspicion is high, explore regardless of US findings
Other Tests
- Generally not needed
- Do not order tests that delay surgery
Classification & Staging
By Type
| Type | Description |
|---|---|
| Intravaginal | Most common; within tunica vaginalis; adolescents |
| Extravaginal | Outside tunica; neonates; entire cord twists |
By Duration
- Hyperacute (under 6 hours) — good prognosis
- Acute (6-24 hours) — moderate prognosis
- Subacute/missed (over 24 hours) — usually non-viable
Management
Immediate — Surgical Emergency
| Priority | Action |
|---|---|
| Call urology urgently | Immediate |
| Analgesia | IV morphine |
| NBM | For surgery |
| Consent for surgery | Exploration, detorsion, orchidopexy, +/- orchidectomy |
Manual Detorsion (Temporising)
- "Open the book" — externally rotate affected testis
- May relieve pain temporarily
- NOT a substitute for surgery
- Still needs exploration
Surgical Exploration
| Procedure | Notes |
|---|---|
| Midline or scrotal incision | Surgeon preference |
| Detorsion | Untwist cord |
| Assess viability | Colour, bleeding after warming |
| Orchidopexy | Fix testis to scrotum (3-point) |
| Bilateral fixation | Bell clapper usually bilateral |
| Orchidectomy | If non-viable |
Prosthesis
- Can insert testicular prosthesis later if orchidectomy needed
Complications
Of Torsion
- Testicular infarction/loss
- Subfertility (antibodies to damaged testis may affect contralateral)
- Atrophy
Of Surgery
- Wound infection
- Haematoma
- Chronic pain
- Prosthesis complications
Prognosis & Outcomes
Salvage Rates
| Duration | Salvage |
|---|---|
| Under 6 hours | Over 90% |
| 6-12 hours | 50% |
| Over 12 hours | Under 10% |
Fertility
- Usually preserved if one testis viable
- May be reduced if bilateral or delayed
Evidence & Guidelines
Key Guidelines
- BAUS/RCEM Joint Statement on Testicular Torsion
- EAU Guidelines on Paediatric Urology
Key Evidence
- Time to surgery is most important factor for salvage
- Clinical diagnosis is sufficient for exploration
Patient & Family Information
What is Testicular Torsion?
Testicular torsion is when the testicle twists inside the scrotum, cutting off its blood supply. This is an emergency.
Symptoms
- Sudden severe pain in one testicle
- Swelling
- Feeling sick or vomiting
What Should I Do?
- Go to A&E immediately
- Do not wait — the testicle needs blood supply restored within hours
Treatment
- Emergency surgery to untwist the testicle
- Stitches to stop it happening again
- If the testicle is damaged, it may need to be removed
Resources
References
Key Studies
- Sharp VJ, et al. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840. PMID: 24364549
- Mellick LB, et al. Testicular torsion: a time-sensitive diagnosis. Pediatr Emerg Care. 2019;35(11):799-804. PMID: 31688683
Guidelines
- Radmayr C, et al. EAU Guidelines on Paediatric Urology. 2021.