Testicular torsion
Testicular torsion is twisting of the spermatic cord causing testicular ischemia, presenting with acute severe unilateral scrotal pain, a swollen high-riding testis in a horizontal lie, and an absent cremasteric reflex; it is a surgical emergency diagnosed clinically without delaying for imaging, and testicular viability falls from 90-100% within 6 hours of symptom onset to under 10% beyond 24 hours, so immediate surgical exploration with detorsion and bilateral orchiopexy is the definitive treatment.
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What this article covers
- Overview
Definition: testicular torsion is rotation of the testicle around the spermatic cord and its vascular pedicle, causing venous outflow obstruction followed by arterial occlusion, testicular ischemia, and, if untreated, infarction.
- Epidemiology
Most common in males age 12 to 18 years, coinciding with testicular growth during puberty, though torsion can occur at any age, including neonates and older men.
- Risk factors
Bell-clapper deformity, a congenital inadequate fixation of the testis to the tunica vaginalis that leaves the testis abnormally mobile and horizontally oriented within the scrotum, the dominant anatomic predisposition.
- Pathophysiology
Inadequate fixation of the testis within the tunica vaginalis allows the testis to rotate freely on the spermatic cord, the anatomic substrate (bell-clapper deformity) that permits torsion to occur.
- Clinical features
Acute, severe unilateral testicular pain that rapidly progresses in severity over hours is the hallmark presentation, often waking the patient from sleep or beginning during exertion.
- Differential diagnosis
Epididymitis/epididymo-orchitis: a slower, more gradual onset of pain, an intact cremasteric reflex, a testis in normal position (not elevated or horizontal), and pain relief with testicular…
- Diagnosis
The diagnosis is made clinically, established by the combination of acute severe unilateral testicular pain, a high-riding testis with a horizontal lie, and an absent cremasteric reflex; when this…
- Management
First, obtain immediate urologic consultation and prepare for emergent surgical exploration as soon as testicular torsion is suspected or confirmed; this is the single highest-priority action and…
- Complications
Testicular infarction and loss of the testis, the direct consequence of delayed detorsion, with viability falling from 90% to 100% when surgery is performed within 6 hours of symptom onset, to about…
- Prognosis
Outcome is almost entirely time-dependent: testicular viability is 90% to 100% with detorsion within 6 hours of symptom onset, falls to approximately 50% by 12 hours, and drops below 10% beyond 24 hours.
- Prevention
There is no way to prevent the underlying bell-clapper anatomic predisposition, since it is a congenital fixation defect present from birth.
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Related articles
- Epididymitis
Epididymitis is inflammation of the epididymis, most often infectious, causing unilateral scrotal pain and swelling of gradual onset that must be distinguished urgently from testicular torsion. Diagnosis is clinical, supported by a positive Prehn sign and preserved cremasteric reflex, and treatment is empiric ceftriaxone plus doxycycline for age under 35 or STI risk, or levofloxacin alone for age over 35 with enteric-organism risk.
- Orchitis
Orchitis is inflammation of the testis, most commonly viral (mumps) with isolated testicular involvement or bacterial as a contiguous extension of epididymitis (epididymo-orchitis), presenting as testicular pain and swelling that must be distinguished from the surgical emergency of testicular torsion. Diagnosis is clinical, guided by exposure history and preserved cremasteric reflex, with mumps orchitis managed supportively and bacterial epididymo-orchitis treated with the same age- and risk-stratified antibiotics used for epididymitis.
- Hydrocele
Hydrocele is a painless accumulation of serous fluid within the tunica vaginalis, congenital and communicating in infants or acquired and noncommunicating in adults, diagnosed by transillumination and confirmed with scrotal ultrasound; treatment is observation for asymptomatic disease and hydrocelectomy for persistent or symptomatic cases.
- Varicocele
Varicocele is dilation of the pampiniform venous plexus and internal spermatic veins, usually left-sided because of the right-angle insertion of the left gonadal vein into the left renal vein, presenting as a painless, non-transilluminating 'bag of worms' scrotal mass that augments with standing or Valsalva and is a leading cause of male infertility. Diagnosis is clinical, confirmed by scrotal Doppler ultrasound when uncertain, and management is conservative (scrotal support, NSAIDs) for asymptomatic cases without testicular atrophy, escalating to surgical ligation or percutaneous embolization for pain, testicular atrophy, or infertility in a patient desiring fertility.
- Testicular cancer
Testicular cancer is the most common solid tumor in men aged 15 to 35 and is usually cured even when metastatic, because germ cell tumors are exquisitely chemosensitive. A painless testicular mass is worked up with scrotal ultrasound and serum tumor markers, radical inguinal orchiectomy establishes the diagnosis and provides local control, and post-orchiectomy markers plus CT staging then guide surveillance, radiation, retroperitoneal lymph node dissection, or cisplatin-based chemotherapy.
- Spermatocele
Spermatocele is a benign, sperm-containing cystic dilation of the epididymal duct or rete testis, palpated as a painless, mobile, fluctuant paratesticular nodule that transilluminates and appears as an anechoic extratesticular lesion on scrotal ultrasound; asymptomatic spermatoceles require no treatment, while large or painful ones are managed with surgical excision.