Testicular torsion

Overview

Testicular torsion - twisting of the spermatic cord causing testicular ischaemia - is a true urological emergency. Every minute of delay reduces the chance of salvage.

Presentation

•Sudden-onset severe unilateral scrotal pain - often waking from sleep or during activity

•Nausea and vomiting - common systemic features

•Abdominal pain - may be the only symptom; always examine the testes in any male with unexplained abdominal pain

•Absent cremasteric reflex - highly significant; present in almost all cases

•High-riding, elevated testis - spermatic cord shortening draws testis superiorly

•Horizontal testicular lie - due to bell-clapper deformity

•Firm, swollen testis - venous congestion and oedema

🚨
A history of previous episodes of severe scrotal pain that resolved spontaneously suggests intermittent torsion - needs urgent urology referral even without current symptoms.

Investigations

•Diagnosis is clinical - no investigation should delay theatre

•Urinalysis - helps exclude UTI/epididymo-orchitis; negative result supports torsion but does not confirm it

•Bloods (FBC, U&Es, CRP, group and save) - pre-operative workup only

•Colour Doppler ultrasound - second-line; shows absent/reduced blood flow; 'whirlpool sign' (spermatic cord spiral) is specific. Use only if diagnosis genuinely equivocal AND will not delay theatre

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A negative ultrasound does NOT exclude torsion - early or partial torsion may show preserved Doppler flow. High clinical suspicion = go to theatre.

Differential diagnosis

Torsion vs epididymo-orchitis vs torsion of appendix testis
FeatureTesticular torsionEpididymo-orchitisAppendix testis torsion
AgeAdolescent (12-18 yrs); any ageSexually active adults; older menBoys 7-12 yrs
OnsetSudden, severeGradualGradual to moderate
Cremasteric reflexAbsentPresentPresent
UrinalysisNormalMay show pyuriaNormal
Pathognomonic signHorizontal lie, high-riding testisTender epididymisBlue dot sign at upper pole

Feature	Testicular torsion	Epididymo-orchitis	Appendix testis torsion
Age	Adolescent (12-18 yrs); any age	Sexually active adults; older men	Boys 7-12 yrs
Onset	Sudden, severe	Gradual	Gradual to moderate
Cremasteric reflex	Absent	Present	Present
Urinalysis	Normal	May show pyuria	Normal
Pathognomonic sign	Horizontal lie, high-riding testis	Tender epididymis	Blue dot sign at upper pole

⚠️
History and examination cannot reliably exclude torsion - clinical suspicion alone mandates immediate surgical referral. Do not wait for imaging.

Management

Immediately
1Refer to urology (or paediatric surgery in children) immediately on clinical suspicion
2Keep nil by mouth
3Do not delay for imaging or bloods
↓
Surgical
1Scrotal exploration - surgical detorsion and assessment of viability
2Bilateral orchidopexy - performed on both testes (bell-clapper deformity is bilateral in up to 40%)
3Orchidectomy - if testis non-viable
↓
Viable testis
Detorsion + bilateral orchidopexy
Non-viable testis
Orchidectomy + contralateral orchidopexy

Complications

•Testicular necrosis/orchidectomy - primary complication of delayed treatment

•Testicular atrophy - reperfusion injury even after salvage

•Impaired fertility - ~36-39% of patients; direct damage and autoimmune changes

•Contralateral torsion - up to 40% if contralateral testis not fixed (bilateral bell-clapper deformity)

Prognosis

< 6 hours
~90-100% testicular salvage rate
6-12 hours
~50% salvage rate
> 24 hours
< 10% salvage rate - orchidectomy likely