• Consider diagnosis in any male with lower abdominal or groin pain.
• Time-dependent entity – make diagnosis and consult early if high suspicion.

• Testicular torsion occurs when the spermatic cord, which provides blood flow to the testicle, becomes twisted and leading to potential ischemia and venous obstruction.
• It is most commonly seen in neonates and males between the ages of 12 and 18, although it can occur at any age.
• Considered a surgical urologic emergency and requires prompt treatment to prevent permanent damage to the testicle, and after eight hours of ischemia it is believed the testis can suffer irreversible damage including infertility in the future, even with one normal testis.
• Caused by various factors, including trauma to the scrotum, inflammation, or congenital conditions that cause the testicle to be improperly positioned within the scrotum.
• Symptoms of testicular torsion include sudden, severe testicular pain, swelling of the scrotum, and nausea or vomiting.
• Its prevalence is 25-50 percent in those hospitalized with acute scrotal pain.

Common signs and symptoms:

• Severe pain in the scrotum or testicle.
• Swelling or redness in the scrotum.
• A feeling of heaviness or aching in the scrotum.
• Nausea and vomiting.
• Lower abdominal pain.

Physical Exam Findings

• Asymmetric high-riding testis.
• Testicular swelling and erythema.
• Tenderness around testis.
• Transverse lie of testis (normally longitudinal lie).
• Palpation of a mass above testis that may be tender.
• Absent ipsilateral cremasteric reflex (differentiates this from epididymitis and other causes of scrotal pain, where reflex remains intact).

Ultrasound

• Usually history and physical examination is sufficient to make the diagnosis, however if uncertain can urgently obtain doppler ultrasonography to examine the testis up to the spermatic cord at the level of the internal ring.
  • Will show absent or decreased blood flow.
  • If still uncertain after ultrasonography but the diagnosis is strongly suspected, urologic referral and surgical exploration is recommended.
• Sensitivity of 82% and specificity of 100%.

Differential Diagnoses:

• Epididymitis / Orchitis.
• Testicular trauma.
• Torsion of appendix testis.
• Varicocele.
• Incarcerated hernia.
• Hydrocele.
• Hematoma.

• Surgical consultation with urology should not be delayed, but manual detorsion can be attempted in the emergency department, as restoration of blood flow is critical.
  • This can be achieved by rotating the affected testis away from midline, either clockwise for the right testis or counter-clockwise for the left testis when standing at the foot of the bed of a supine patient.
    • Classically it was presumed the testis rotates medially when torsed, however some studies have shown that lateral rotation may be present in ⅓ of cases.
    • Degree of twisting may be more than 360 degrees, therefore more than one round of detorsion may be required.
    • If successful, will have decrease in pain, lower positioning of testis, return of longitudinal orientation, normal flow on doppler ultrasound and improved testis salvageability.
    • Can give intravenous sedation or local anesthetic if required, although may mask ongoing torsion if testis was twisted greater than 180 degrees.
  • If the testis is successfully manually detorsed, surgical fixation to prevent future occurrences is recommended.
  • Urgent surgical intervention to detorse and fixate the testis is warranted in any case of testicular torsion, so urological referral should be made for any suspected case.

1. Arce JD, Cortes M, Vargas JC. Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis. Pediatr Radiol. 2002;32:485-91

   
   

2. Eyre RC. Acute Scrotal Pain. In: UpToDate. Waltham, MA. Accessed December 22, 2022. Available at: https://www.uptodate.com/contents/acute-scrotal-pain-in-adults?search=testicular%20torsion&source=search_result&selectedTitle=1~37&usage_type=default&display_rank=1#H4

   
   

3. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol 1984; 132:89.

   
   

4. Cummings JM, Boullier JA, Sekhon D, Bose K. Adult testicular torsion. J Urol 2002; 167:2109.

   
   

1. Manual Detorsion Guide:
   https://emedicine.medscape.com/article/1413565-overview