Testicular Torsion - Quick Consult
Last Updated / Reviewed: 4/5/2021

Definition
Key History
Key Physical Exam
Risk Factors for Testicular Torsion
Differential Diagnosis
Torsion vs. Epididymitis Table
Testicular Salvage Rates Table
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment

Definition

In testicular torsion the spermatic cord that provides the blood supply to a testicle is twisted, cutting off the blood supply, often causing orchalgia. Prolonged testicular torsion will result in the death of the testicle and surrounding tissues.

It is also believed that torsion occurring during fetal development can lead to the so-called neonatal torsion or vanishing testis, and is one of the causes of an infant being born with monorchism.

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Key History

  • History of similar pain that resolved spontaneously (up to 41%)
  • Sudden onset pain in inguinal or lower abdomen
  • Key: Sometimes only lower abdominal pain without inguinal or scrotal pain
  • Often associated with nausea and vomiting
  • Commonly occurs after sleep, exertion, or direct trauma
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Key Physical Exam

  • Hemiscrotum extremely painful to touch – limiting exam
  • Hemiscrotum swollen, tender and firm
  • Reactive hydrocele may be present.
  • May have high riding testis with a transverse lie – classic finding
  • Loss of cremasteric reflex has strong association with torsion.
  • Blue dot sign – Blue/black dot in scrotum associated with testicular appendage torsion
  • Prehn’s sign – elevation of scrotum relieves pain from epididymitis but not torsion (not reliable)
  • Opposite testis should be examined for bell-clapper deformity.
  • Tenderness of the testicle and epididymis
  • Testicular lie: Vertical is normal, horizontal is abnormal
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Risk Factors for Testicular Torsion

Age

Torsion occurs more commonly in children and adolescents, while epididymitis is more common in older adolescents and young adults; however, there is a significant age overlap in these groups. The testicles’ scrotal attachments are poorly developed in neonates, making them somewhat more prone to torsion.

The most common age at which testicular torsion occurs is during puberty, and the second most common is in the newborn. Although testicular torsion can occur at any age, the presentation of a patient under the age of 17 with scrotal pain should evoke a rapid response from the office or emergency department staff and should be considered a testicular torsion until proven otherwise.

The Bell-Clapper Deformity

The normal testicle is surrounded by tunica vaginalis, including an attachment to the posterior scrotal wall. In those persons with the bell-clapper deformity, the tunica completely surrounds the testicle and extends above it, preventing the attachment to the posterior scrotal wall. The testicle is freely movable on the spermatic cord, and it can twist on the spermatic cord.

Prior Torsion

Patients with torsion should have surgical fixation of the non-torsed testicle in order to avoid a recurrent torsion. Presumably, the same anatomic abnormality that resulted in the initial torsion will affect the other testicle. If the patient with a history of torsion has not had surgical fixation of the other testicle, he is at high risk for recurrent torsion.

Undescended Testicle:

The undescended testes undergo torsion 10 times as frequently as normally descended testes.

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Differential Diagnosis

  • Epididymitis
  • Orchitis
  • Torsion of the appendix testis
  • Fournier’s gangrene
  • Urinary tract infection
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Torsion vs. Epididymitis Table

Epididymitis is the most frequent misdiagnosis in cases of testicular torsion. The delay caused by the misdiagnosis can result in testicular loss. It is important to be able to differentiate the two or, if unable to do so, order an imaging study. The clinician must be able to reasonably conclude that the problem is epididymitis or consider an imaging study to rule out torsion.

Torsion vs. Epididymitis

Torsion Epididymitis
Onset of pain: acute Onset of pain: gradual
Vomiting and anorexia are common Vomiting and anorexia are uncommon
History of prior episodes No history of prior episodes
Fever and dysuria unusual Fever in 14% to 28% of cases
Cremasteric reflex absent Cremasteric reflex present
Testicular lie: horizontal Testicular lie: vertical
Negative Prehn's sign Positive Prehn's sign
No urethral discharge Urethral discharge possible

It may be possible to differentiate tenderness in the epididymis versus the testicle early in either process. Later in the process, however, diffuse tenderness to palpation of both the epididymis and testicle can occur with both clinical entities. In addition, although pyuria is typical of epididymitis, it can occur in torsion, as inflammation becomes widespread.

One group of researchers found that patients with 3 findings from the following list had definite epididymitis, and those with 2 findings were probable cases of epididymitis:
  • Gradual onset of symptoms
  • Recent urinary tract instrumentation or surgery
  • Dysuria or recent urinary tract infection
  • Significant elevation in temperature – over 101 F (38.3 F)
  • Localized tenderness and induration of epididymis
  • Abnormal urinalysis
It is common for some doubt to remain, in which case the practitioner may consider ordering an imaging study.

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Testicular Salvage Rates Table

Torsion Salvage Rates
Approximate % of Salvage Rate If Correction Occurs Within
100% 3 hours
83% to 90% 5 hours
75% 8 hours
50% to 70% 10 hours
10% to 20% 10 to 24 hours

Viability is rare if intervention is delayed for 24 hours or longer from the onset of symptoms.
In series of 238 patients with acute scrotal pain, there was a high probability of testicular salvage if intervention occurred within 6 hours of the onset of pain, 50% between 6 and 48 hours, and no salvage was achieved after 48 hours. One conclusion from this study was that a testis should not be presumed necrotic and unsalvageable if fewer than 48 hours have elapsed since the onset of symptoms.

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Diagnostic Testing

Text / literature information and recommendations include:
  1. Labs:
    • Urinalysis – may be unremarkable, up to 10% have pyuria
    • CBC – often absence of leukocytosis
  2. Imaging:
    • Color Doppler Ultrasound – Test of Choice – Sensitivity 86-100% and Specificity 100%
    • Radioisotope Scans – less practical – may delay diagnosis - Sensitivity 80-100% and Specificity 89-100%
    • Doppler Ultrasound - Sensitivity 80-90%, Specificity 80-90%
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Clinical Risk and Safety Pearls

  • In a man under 40 with a painful testicle, assume torsion until proven otherwise.
  • If high suspicion for torsion, contact a urologist immediately, do not wait on Doppler findings in patients strongly suspicious of torsion. This is a seconds-to-minutes emergency.
  • Be aware that patient’s may undergo spontaneous detorsion and complete resolution of symptoms. If discharged, provide discharge instructions to return immediately for change in condition.
  • Nearly 41% of patients report a history of a similar pain that resolved spontaneously.
  • Torsion commonly occurs after sleep, exertion, or trauma.
  • Torsion may be misdiagnosed as epididymitis.
  • Differentiation of Torsion vs. Epididymitis Table
  • Diagnosis of testicular torsion must be made rapidly, since salvage of the testicle becomes increasingly difficult with surgical delay. Based on several series, the following salvage rates have been reported:
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Treatment

Common text / literature recommendations include:
  1. Consultation with Urologist
  2. IV access
  3. Pain control
  4. NPO
  5. Manual detorsion – testis usually twist medially – only a temporary solution – surgical follow-up required
    1. To manually detorse, rotate the anterior aspect of the testicle towards the ipsilateral thigh - like opening a book - the testicle may need to be rotated up to 360 degrees. If successful the patient should experience marked relief of pain.
  6. Surgery is curative.

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  1. Bowlin PR, Gatti JM, Murphy JP. Pediatric testicular torsion. Surg Clin North Am. 2017;97(1):161-172.
  2. Colaco M, Heavner M, Sunaryo P, Terlecki R. Malpractice litigation and testicular torsion: A legal database review. J Emerg Med. 2015;49(6):849-854.
  3. DaJusta DG, Granberg CF, Villanueva C, Baker LA. Contemporary review of testicular torsion: New concepts, emerging technologies and potential therapeutics. J Pediatr Urol. 2013;9(6 Pt A):723-730.
  4. Osumah TS, Jimbo M, Granberg CF, Gargolio PC. Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes. J Pediatr Urol. 2018;14(5):394-401.
  5. Selbst SM. Pediatric emergency medicine: Legal briefs. Pediatr Emerg Care. 2010;26(4):316-319.
  6. Selbst SM. Pediatric emergency medicine: Legal briefs. Pediatr Emerg Care. 2012;28(4):xxx.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.

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