Testicular Torsion: Symptoms, Causes & Emergency Treatment

What Is Testicular Torsion?

Testicular torsion occurs when the testicle rotates on the spermatic cord, twisting and cutting off its blood supply. This causes sudden, severe pain and requires emergency surgery within 6 hours to prevent permanent damage or loss of the testicle. It most commonly affects adolescent males between 12-18 years old.

Testicular torsion is a urological emergency that occurs when the testicle rotates, causing the spermatic cord to twist. The spermatic cord contains blood vessels that supply the testicle, and when it twists, blood flow to the testicle is compromised or completely cut off. Without adequate blood supply, the testicular tissue begins to die within hours, making prompt diagnosis and treatment absolutely critical.

The condition occurs because of an anatomical variation called the "bell clapper deformity," which is present in approximately 12% of males. In this condition, the testicle is not properly anchored within the scrotum by a structure called the tunica vaginalis. This allows the testicle to swing freely, much like the clapper inside a bell, and makes it susceptible to twisting on its spermatic cord. Importantly, when one testicle has this deformity, the other usually does too, which is why surgeons typically fix both testicles during surgery.

Understanding the mechanics of torsion helps explain why it's so serious. The spermatic cord contains the vas deferens (which carries sperm), nerves, and most critically, the testicular artery and veins. When torsion occurs, the veins are typically compressed first, leading to congestion and swelling. As the torsion continues or tightens, the artery becomes compressed as well, completely cutting off fresh blood supply. Without oxygenated blood, the testicular cells begin to die through a process called ischemia.

Types of Testicular Torsion

There are several types of testicular torsion, each with different characteristics and treatment considerations. Understanding these variations helps medical professionals provide appropriate care.

Intravaginal torsion is the most common type, accounting for about 90% of cases. It occurs within the tunica vaginalis (the membrane surrounding the testicle) and is what most people mean when they refer to testicular torsion. This type typically affects adolescents and young adults and is associated with the bell clapper deformity.

Extravaginal torsion occurs outside the tunica vaginalis and is most commonly seen in newborns. In this type, the entire testicle and its covering membranes twist together. It often occurs before birth or in the first few weeks of life, before the testicle becomes fixed to the scrotal wall. This form has a poorer prognosis because it's often not recognized until significant damage has occurred.

Intermittent torsion involves repeated episodes of partial torsion that spontaneously resolve. Patients experience recurring bouts of scrotal pain that come and go. While symptoms may temporarily improve, these patients remain at high risk for complete torsion and typically require preventive surgery (orchiopexy) to fix the testicles in place.

Who Is at Risk?

While testicular torsion can occur at any age, certain factors increase the risk. The condition shows a bimodal distribution, with peaks in the neonatal period (first 30 days of life) and during puberty (12-18 years). During puberty, rapid testicular growth may trigger torsion, especially in those with the bell clapper deformity.

Other risk factors include a history of previous torsion or intermittent testicular pain, cold weather (which can trigger cremasteric muscle contraction), and physical activity or minor trauma to the groin area. However, it's important to note that torsion often occurs without any obvious trigger and frequently happens during sleep.

What Are the Symptoms of Testicular Torsion?

The main symptoms of testicular torsion include sudden, severe pain in one testicle that may radiate to the lower abdomen, scrotal swelling and redness, nausea and vomiting, and a testicle that appears higher than normal or at an abnormal angle. The pain typically begins suddenly and does not improve with rest or position changes.

The symptoms of testicular torsion are typically dramatic and unmistakable, though they can sometimes be confused with other conditions. Recognizing these symptoms quickly is crucial because every minute counts when blood supply is compromised. Understanding the full picture of how torsion presents can help ensure rapid medical attention.

The hallmark symptom is sudden onset of severe scrotal pain. Unlike pain from an infection, which typically develops gradually over hours or days, torsion pain comes on suddenly and is often excruciating from the start. Many patients describe being woken from sleep by the pain, which is a classic presentation. The pain is usually localized to one testicle but may radiate to the lower abdomen or groin on the same side.

Physical examination reveals several characteristic findings. The affected testicle is typically very tender to touch and may be swollen. A distinctive sign is the "high-riding" testicle - the affected testicle often appears higher in the scrotum than normal because the twisting shortens the spermatic cord. The testicle may also lie at an abnormal horizontal angle (transverse lie) rather than the normal vertical position.

Classic Signs and Symptoms

• Sudden, severe scrotal pain: The pain begins abruptly and is often described as sharp or stabbing. It may occur during physical activity, after minor trauma, or spontaneously during sleep.
• Scrotal swelling: The scrotum on the affected side typically becomes swollen as blood congests in the testicle.
• Scrotal redness: The scrotal skin may appear red or darkened due to inflammation and blood congestion.
• Nausea and vomiting: These symptoms occur in approximately 50% of patients due to the severity of pain and autonomic nerve stimulation.
• Abdominal pain: Lower abdominal pain on the affected side is common because testicular nerves share pathways with abdominal nerves.
• Absent cremasteric reflex: Stroking the inner thigh normally causes the testicle to retract. This reflex is typically absent in torsion, though this finding alone is not definitive.

Symptoms in Newborns and Infants

Testicular torsion in newborns presents differently and can be challenging to diagnose. Unlike older children and adolescents, newborns cannot verbalize pain. Parents and healthcare providers should watch for signs such as a swollen or firm scrotum, discoloration of the scrotal skin (which may appear dark or bluish), and irritability or poor feeding. The testicle may feel hard and fixed rather than soft and mobile.

Neonatal torsion often occurs before birth or within the first 30 days of life. Unfortunately, prenatal torsion is usually discovered after the testicle has already been damaged. When torsion is discovered at birth, the affected testicle often already shows signs of infarction (tissue death), and orchiectomy (removal) rather than salvage is frequently necessary.

What Causes Testicular Torsion?

Testicular torsion is primarily caused by the "bell clapper deformity," an anatomical variant present in about 12% of males where the testicle is not properly anchored in the scrotum. This allows the testicle to rotate freely on the spermatic cord. Torsion can be triggered by physical activity, cold temperatures, trauma, or may occur spontaneously during sleep.

Understanding the causes of testicular torsion requires knowledge of normal testicular anatomy and what goes wrong to allow torsion to occur. In most males, the testicle is firmly attached to the inside of the scrotum by a structure called the tunica vaginalis. This attachment normally prevents the testicle from rotating on its spermatic cord. However, in some males, this attachment is abnormal or absent.

The bell clapper deformity is the underlying cause in most cases of testicular torsion. In this anatomical variant, the tunica vaginalis completely surrounds the testicle and epididymis, leaving them suspended in the scrotum like a clapper inside a bell. This allows the testicle to swing freely and rotate within the tunica vaginalis. The deformity is present from birth and is typically bilateral, meaning both testicles are affected, which explains why surgeons fix both testicles during surgery.

While the bell clapper deformity creates the possibility of torsion, various factors can trigger an actual torsion event. However, it's important to note that torsion often occurs without any identifiable trigger.

Triggering Factors

Several factors have been associated with triggering testicular torsion in susceptible individuals, though causation is not always clear.

Physical activity and exercise have been implicated in some cases of torsion. Activities involving sudden movements, jumping, or direct impact to the groin area may trigger torsion in someone with the bell clapper deformity. However, many cases occur at rest or during sleep, so physical activity is not a necessary precursor.

Cold temperatures may contribute to torsion through contraction of the cremasteric muscle, which surrounds the spermatic cord and raises the testicle. Some studies have noted increased incidence of torsion during winter months, though this association is not definitive. The theory is that muscle contraction in response to cold may initiate or facilitate rotation of a freely mobile testicle.

Trauma to the scrotum or groin can trigger torsion, though direct trauma accounts for only a small percentage of cases. Even minor trauma may be sufficient to cause torsion in someone with the anatomical predisposition.

Rapid testicular growth during puberty is thought to be one reason why torsion peaks during adolescence. As the testicle grows larger, it may become more prone to rotation, especially if the attachment to the scrotal wall has not developed adequately.

Sleep is when many torsion events occur, possibly due to cremasteric muscle contractions during REM sleep. The classic presentation of being woken from sleep by sudden scrotal pain is well documented in medical literature.

Risk Factors

• Age 12-18 years: The highest risk period due to rapid testicular growth during puberty
• Neonatal period: Second peak of incidence in the first 30 days of life
• Previous torsion or intermittent torsion: History of scrotal pain episodes indicates risk
• Family history: Some evidence suggests familial predisposition
• Undescended testicle (cryptorchidism): May have increased risk due to abnormal anatomy
• Bell clapper deformity: The underlying anatomical cause in most cases

When Should You Seek Emergency Care?

Seek emergency medical care immediately for any sudden, severe scrotal pain. Do not wait to see if symptoms improve - testicular torsion is a time-sensitive emergency where delays of even a few hours can mean the difference between saving and losing the testicle. Go directly to an emergency department; do not wait for a clinic appointment.

The decision to seek emergency care for scrotal pain should err strongly on the side of caution. While not all scrotal pain is testicular torsion, the consequences of missing or delaying treatment for torsion are severe and irreversible. Medical professionals follow the principle that any acute scrotal pain is torsion until proven otherwise, and you should approach it the same way.

The critical nature of testicular torsion cannot be overstated. Testicular salvage rates are directly correlated with the duration of symptoms. If surgery is performed within 6 hours of symptom onset, the testicle can be saved in 90-100% of cases. Between 6-12 hours, salvage rates drop to approximately 50%. After 12 hours, only about 10% of testicles can be saved, and after 24 hours, salvage is extremely unlikely.

These time-dependent outcomes explain why immediate action is essential. Every hour of delay increases the risk of permanent damage. Even if you're uncertain whether your symptoms represent true torsion or something less serious, the potential consequences of waiting make immediate evaluation the only reasonable choice.

When to Go to the Emergency Room

Go directly to an emergency department if you experience:

• Sudden onset of severe scrotal or testicular pain
• Scrotal swelling that develops over minutes to hours
• A testicle that appears higher than normal or at an abnormal angle
• Scrotal pain accompanied by nausea or vomiting
• Scrotal pain that woke you from sleep
• Any scrotal pain in a child who cannot clearly describe symptoms

How Is Testicular Torsion Diagnosed?

Testicular torsion is primarily diagnosed through physical examination, looking for a tender, swollen testicle, absent cremasteric reflex, and abnormal testicular position. Doppler ultrasound can assess blood flow but should not delay surgery when clinical suspicion is high. The principle is: when in doubt, operate - because missing torsion can mean losing the testicle.

The diagnosis of testicular torsion presents a clinical challenge because rapid diagnosis is essential, yet definitive confirmation typically requires surgery. Medical professionals must balance the need for diagnostic certainty against the time pressure created by ongoing ischemia. In practice, when clinical suspicion for torsion is high, surgery proceeds without extensive testing because the consequences of delayed treatment are worse than the consequences of negative surgical exploration.

Physical examination remains the cornerstone of diagnosis. The physician will examine both testicles, comparing them for position, tenderness, and reflexes. Classic findings suggesting torsion include a high-riding testicle (elevated position due to cord shortening), horizontal lie (testicle oriented side-to-side rather than up-and-down), severe tenderness, and absence of the cremasteric reflex.

The cremasteric reflex is tested by stroking or pinching the inner thigh. Normally, this causes the testicle on that side to rise toward the body. In testicular torsion, this reflex is typically absent. However, while a present cremasteric reflex makes torsion less likely, it doesn't completely rule it out, and an absent reflex doesn't confirm torsion.

Diagnostic Tests

Doppler ultrasound is the most commonly used imaging test for suspected testicular torsion. It uses sound waves to visualize the testicle and assess blood flow through the testicular vessels. In torsion, blood flow to the affected testicle is reduced or absent. Ultrasound can also help identify other causes of scrotal pain, such as epididymitis or testicular tumors.

However, ultrasound has limitations. It is operator-dependent, meaning results vary based on the skill and experience of the technician. It may not be available 24/7 at all facilities. Most importantly, ultrasound should not delay surgery when clinical suspicion is high. The test takes time, and every minute matters in torsion. If a physician strongly suspects torsion based on clinical examination, surgery should proceed without waiting for ultrasound confirmation.

Urinalysis is often performed to help rule out urinary tract infection or epididymitis, which can present with similar symptoms. In torsion, urinalysis is typically normal, while infection may show white blood cells or bacteria.

Blood tests may be performed as part of pre-operative preparation but do not help diagnose torsion itself. Complete blood count and coagulation studies are standard before surgery.

Differential Diagnosis

Several other conditions can cause acute scrotal pain and must be considered in the differential diagnosis:

• Epididymitis: Inflammation of the epididymis, often from infection. Pain typically develops gradually over days rather than suddenly. More common in sexually active adults.
• Torsion of appendix testis: The appendix testis is a small vestigial structure attached to the testicle. Its torsion causes pain but is not a surgical emergency. A "blue dot sign" (visible through the scrotal skin) is characteristic.
• Orchitis: Inflammation of the testicle itself, often viral (such as with mumps). Typically associated with systemic illness.
• Incarcerated inguinal hernia: Bowel protruding into the scrotum and becoming trapped. Causes scrotal swelling and pain.
• Trauma: Direct injury to the testicle can cause pain and swelling.
• Testicular tumor: Usually presents as painless swelling but can occasionally cause pain.

How Is Testicular Torsion Treated?

Testicular torsion is treated with emergency surgery (orchiopexy) to untwist the testicle and fix it to the scrotal wall. Both testicles are typically fixed to prevent future torsion. If the testicle is non-viable, it must be removed (orchiectomy). Manual detorsion may be attempted as a temporary measure before surgery but is not a substitute for surgical repair.

The treatment of testicular torsion is surgical and urgent. While some temporary measures may be attempted, definitive treatment requires an operation to untwist the spermatic cord, restore blood flow, and fix the testicle in place to prevent recurrence. The goals of treatment are to save the affected testicle when possible and to prevent torsion of the opposite testicle.

Surgery for testicular torsion, called orchiopexy, involves making an incision in the scrotum, identifying the twisted spermatic cord, untwisting it (detorsion), assessing the testicle's viability, and if viable, suturing the testicle to the scrotal wall to prevent future torsion. Because the bell clapper deformity is usually bilateral, the opposite testicle is also fixed during the same surgery.

The surgical approach involves opening the scrotum to directly visualize the affected testicle. Once exposed, the surgeon can see the degree of torsion (which can range from 180 to 720 degrees or more) and the condition of the testicle. The spermatic cord is untwisted, and the testicle is observed for signs of returning blood flow. Changes in color from dusky purple to pink indicate viable tissue.

Surgical Treatment

Orchiopexy (testicular fixation) is performed when the testicle is viable after detorsion. The procedure involves placing sutures through the tunica albuginea (the covering of the testicle) and attaching it to the dartos fascia of the scrotum. This anchors the testicle and prevents it from rotating in the future. The opposite testicle is fixed during the same surgery because the anatomical predisposition is usually bilateral.

Orchiectomy (testicle removal) is necessary when the testicle is clearly non-viable. Signs of non-viability include a testicle that remains dark, firm, and does not pink up after detorsion, indicating that the tissue has died. Leaving a non-viable testicle can lead to infection, chronic pain, and potential harmful immune responses against the remaining testicle. Even when orchiectomy is necessary, the opposite testicle should still be fixed.

Manual Detorsion

In some cases, physicians may attempt manual detorsion - physically rotating the testicle to untwist it without surgery. This is done by rotating the testicle outward (like opening a book), as most torsions twist inward. Successful detorsion typically brings dramatic pain relief.

However, manual detorsion has significant limitations. It may not fully untwist the testicle, it does not address the underlying anatomical problem, and it does not prevent recurrence. Even if manual detorsion is successful, surgery is still required to fix the testicle. Manual detorsion is best viewed as a temporizing measure to restore blood flow while preparing for surgery, not as definitive treatment.

Post-Operative Care

Recovery after orchiopexy typically takes several weeks. Patients should expect:

• Pain management: Pain is usually well controlled with over-the-counter analgesics or mild prescription pain medication for the first few days
• Activity restrictions: Physical activity and sports should be avoided for several weeks while healing occurs
• Sexual activity: Typically restricted for several weeks to allow complete healing
• Scrotal support: Wearing supportive underwear helps reduce discomfort during recovery
• Follow-up: Return visits ensure proper healing and monitor the testicle's condition

What Are the Possible Complications?

Complications of testicular torsion include testicular atrophy (shrinkage), loss of the testicle requiring orchiectomy, potential impacts on fertility, chronic pain, and psychological effects. The most important factor determining outcome is how quickly treatment is received - delays significantly increase the risk of complications.

The complications of testicular torsion are primarily related to delayed treatment and the resulting damage to the testicle from prolonged lack of blood flow. Even with successful detorsion and fixation, some degree of testicular injury may have occurred, leading to various short-term and long-term consequences. Understanding these potential complications underscores the importance of seeking immediate care.

The most significant factor determining whether complications occur is the duration of torsion before treatment. Testicles that are detorsed within 6 hours typically have excellent outcomes with minimal complications. As time progresses, the risk of permanent damage increases substantially.

Testicular Loss

The most serious complication is complete loss of the testicle, requiring orchiectomy. This occurs when the ischemia (lack of blood flow) has been so prolonged that the testicular tissue has died and cannot be saved. Leaving a non-viable testicle in place is not advisable because it can become infected, cause chronic pain, and potentially trigger immune responses that could affect the remaining testicle.

When orchiectomy is necessary, patients should understand that life with one testicle is normal. The remaining testicle typically produces sufficient testosterone for normal hormonal function and adequate sperm for fertility. Testicular prostheses are available for cosmetic purposes if desired.

Testicular Atrophy

Even when a testicle is saved, it may undergo atrophy (shrinkage) if significant damage occurred. This happens because some of the testicular tissue died during the torsion but not enough to require removal. Over the following months, the damaged portion of the testicle shrinks, leaving a smaller but still functional organ.

Fertility Considerations

Many patients and families worry about fertility after testicular torsion. The good news is that most men maintain normal fertility even after losing one testicle, as a single testicle typically produces adequate sperm. However, some considerations apply:

• If both testicles are damaged (extremely rare), fertility may be significantly impacted
• The remaining testicle may show some decline in sperm parameters, though usually not enough to cause infertility
• Some research suggests possible antibody formation against sperm after torsion, though clinical significance is debated
• Overall, studies show that men with a history of unilateral torsion have fertility rates similar to the general population

Can Testicular Torsion Be Prevented?

Testicular torsion cannot be reliably prevented because the underlying anatomical predisposition (bell clapper deformity) is present from birth. However, boys and young men with intermittent scrotal pain should be evaluated, as elective orchiopexy can prevent future torsion. The opposite testicle is always fixed during torsion surgery because the deformity is usually bilateral.

Unfortunately, there is no way to prevent the first episode of testicular torsion in someone who has the anatomical predisposition but is unaware of it. The bell clapper deformity is present from birth, and there are no screening tests to identify affected individuals before they experience symptoms. Most cases of torsion occur without warning in otherwise healthy young men.

However, prevention is possible in certain situations. For individuals who have experienced intermittent testicular pain - episodes of scrotal pain that come and go - urological evaluation is important. This pattern may represent intermittent torsion, where the testicle partially twists and then spontaneously untwists. These individuals are at high risk for complete torsion and can benefit from elective orchiopexy to fix the testicles in place before a serious torsion event occurs.

Additionally, when one testicle has undergone torsion, the opposite testicle should always be fixed during the same surgery. Because the bell clapper deformity is typically bilateral, the contralateral testicle has the same risk of torsion and should be secured. This is standard practice and an important preventive measure.

Education and Awareness

While the condition itself cannot be prevented, educating young men and their families about the symptoms of testicular torsion can help ensure rapid treatment when it does occur. Key messages include:

• Sudden severe scrotal pain is an emergency requiring immediate medical attention
• Do not wait to see if symptoms improve - time is critical
• Intermittent scrotal pain episodes should prompt medical evaluation
• It's not embarrassing to seek care for genital symptoms - medical professionals see these conditions regularly