Testicular Torsion
Testicular torsion is a urological emergency caused by twisting of the spermatic cord with compromise of testicular blood flow. Ischemia progresses rapidly — salvage depends on intervention within 4–8 hours of symptom onset — and surgical exploration with detorsion + bilateral orchiopexy is the definitive treatment. The clinical diagnosis takes priority over imaging; in any case with a high pretest probability, the patient goes to the operating room, not the ultrasound suite.[1][2][3]
Epidemiology
- Incidence: ~1 in 4,000 males <25 years annually
- Accounts for 10–15% of acute scrotal disease in children
- Bimodal age distribution:
- Neonatal period (first year of life) — often extravaginal torsion, frequently missed on initial evaluation
- 12–18 years — the peak adolescent incidence; typically intravaginal torsion on bell-clapper anatomy
- Can occur at any age, including adult life[1][4]
Risk Factors
| Risk factor | Mechanism |
|---|---|
| Bell-clapper deformity | Abnormal high investment of the tunica vaginalis → testis hangs freely like a clapper in a bell → excessive mobility enables intravaginal torsion |
| Prior history of torsion | ~50% report antecedent similar self-resolving episodes |
| Family history | Genetic predisposition to bell-clapper anatomy |
| Cold weather | Hyperactive cremasteric reflex |
| Rapid pubertal growth | Testicular enlargement in an already loose investment |
| Antecedent trauma | Minor scrotal trauma can precipitate torsion in predisposed anatomy |
Pathophysiology
The spermatic cord twists around its longitudinal axis within (or outside of) the tunica vaginalis:
- Venous outflow is obstructed first (low-pressure venous system yields to twist before arterial inflow)
- Progressive venous congestion → edema → increasing intratesticular pressure
- Eventually arterial inflow is compromised → global ischemia
- Germ cell apoptosis begins within 2–4 hours; irreversible necrosis within 6–12 hours in complete torsion
Ischemia-reperfusion injury is a second pathophysiologic hit: detorsion restores flow to injured tissue, driving oxidative stress, neutrophil activation, cytokine release, endothelial dysfunction, and further germ cell loss. This explains why even "salvaged" testes frequently undergo partial atrophy and exhibit abnormal semen parameters long-term.[5][6]
Clinical Presentation
Classic symptoms
- Severe, acute, unilateral scrotal pain — the defining presentation
- Onset typically <24 hours
- Nausea and vomiting — present in most cases (partly autonomic, partly referred pain)
- Scrotal swelling, erythema
- Can be associated with lower abdominal or inguinal pain, which may mislead toward non-testicular etiologies in adolescent males
Physical examination
| Sign | Significance |
|---|---|
| High-riding testis with transverse lie | Classic; caused by cord shortening from twist |
| Absent cremasteric reflex | OR 47.6 for torsion[1] — the single strongest exam finding |
| Tender, swollen, firm testicle | Universal |
| Abnormal testicular lie | Transverse or elevated position |
Prior episodes
Up to ~50% of patients report previous similar episodes of self-resolving pain — intermittent torsion–detorsion — an important historical clue that should not be dismissed.[7]
Diagnosis
Clinical diagnosis first
Testicular torsion is primarily a clinical diagnosis. When history and exam are consistent with torsion, immediate surgical exploration is indicated and should not be delayed for imaging. Imaging is reserved for cases with intermediate clinical probability.[3]
TWIST Score
The TWIST score (Testicular Workup for Ischemia and Suspected Torsion) is a validated 7-point clinical decision tool.[4][8]
| Finding | Points |
|---|---|
| Testicular swelling | 2 |
| Hard testis | 2 |
| Absent cremasteric reflex | 1 |
| Nausea / vomiting | 1 |
| High-riding testis | 1 |
Risk stratification (Barbosa):
| Risk | TWIST | Prevalence of torsion | Action |
|---|---|---|---|
| Low | 0–2 | 1–2.2% | No imaging; alternative diagnosis |
| Intermediate | 3–4 | ~22% | Color Doppler US |
| High | 5–7 | ~87% | Urgent surgical exploration |
- AUC 0.924 in meta-analysis — among the best-performing urologic scoring systems
- Appropriate for widespread adoption, particularly in pediatric triage
Imaging — color Doppler ultrasound
When imaging is chosen for intermediate-risk patients:
- Color Doppler ultrasonography is the study of choice
- Sensitivity 100%, specificity 97.9% for detecting torsion[1]
- Key findings:
- Absent or decreased intratesticular blood flow on the affected side
- Whirlpool sign — twisted spermatic cord visible on gray-scale or color Doppler (most specific finding)
- Hypoechoic / heterogeneous parenchyma in late/progressed torsion
A normal ultrasound cannot exclude the diagnosis. Clinical suspicion drives management.[2]
Management
Emergent surgical exploration
Any high-risk or clinically convincing case → operating room without delay. Time is testicle.
Manual detorsion (bridge therapy)
Can be attempted in the ED while awaiting surgical transfer:[2][9]
- Lateral-to-medial rotation ("opening a book") — most torsions are medial; this untwists them
- If pain worsens with that direction, rotate the opposite way (atypical torsion direction)
- Ultrasound guidance may improve success
- Success does NOT obviate surgical fixation — orchiopexy is still required after successful manual detorsion
Timing and salvage rates
| Time from symptom onset | Salvage rate |
|---|---|
| <6 hours | ~90% |
| 6–8 hours | Testicle usually salvageable |
| 8–12 hours | Variable; salvage becomes less reliable |
| >12 hours | Risk of permanent damage / orchiectomy increases significantly |
| >24 hours | Most testes are non-viable |
Nationally, approximately 32% of pediatric torsion cases result in orchiectomy. Higher rates in younger children (ages 1–9: ~50% orchiectomy) — often because of delayed presentation.[10]
Operative Technique — Scrotal Exploration and Orchiopexy
Incision
- Midline raphe incision — allows bilateral access through a single incision; preferred by many pediatric urologists
- Bilateral hemiscrotal incisions — alternative; slightly longer recovery
- Carry through dartos into each hemiscrotum
Delivery and detorsion
- Deliver the affected testis through the dartos pouch
- Detorse the testis by rotating opposite to the direction of twist — palpate the spermatic cord to appreciate the direction
- Wrap in warm moist saline gauze and observe for 10–20 minutes for reperfusion / color return
- Deliver and inspect the contralateral testis (usually normal but confirm absence of bell-clapper and synchronous torsion)
Viability assessment
After observation:
- Pink / viable → orchiopexy
- Dark / dusky with questionable viability → consider tunica albuginea decompression (see below) before making the orchiectomy decision
- Black / clearly necrotic → orchiectomy
Orchiopexy — fixation techniques
Bilateral orchiopexy is mandatory — the bell-clapper anatomy is usually bilateral, and the contralateral testis is at high risk for asynchronous torsion.[11]
Multiple fixation methods exist; all have comparable success when technically well-executed.[12][13][14]
Sutureless dartos pouch (scrotal pouch) orchiopexy
- Create a subdartos pouch below the dartos layer
- Obliterate the partial tunica vaginalis sac
- Place testis in the pouch in an extravaginal position
- Tissue adherence secures the testis — no transparenchymal sutures
- Preserves tunica albuginea and seminiferous tubule integrity
- Kozminski series (1,104 cases, 155 for torsion): 98.7% success, 14 adverse outcomes[14]
Sutured point-fixation (traditional)
- 2–3 sutures through the tunica albuginea to the dartos or scrotal wall
- Nonabsorbable preferred (polypropylene 3-0 or 4-0) — absorbable suture associated with higher recurrence
- Traditional workhorse; comparable efficacy to sutureless[12][13]
Jaboulay fixation (tunica plication)
- Plication of the tunica vaginalis around the testis without transparenchymal sutures
- Head-to-head with sutured point-fixation: no difference in recurrence, return-to-OR, or complications[12]
Eversion of tunica vaginalis
- Evert the tunica vaginalis to create extensive serosal-scrotal adherence
- Lent 1993 series (46 patients): 87.5% salvage, no recurrences[15]
Advanced Salvage — Tunica Albuginea Decompression + Tunica Vaginalis Flap (TVF)
For testes that remain ischemic after detorsion — particularly with prolonged ischemia (12–24+ hours) — tunica albuginea incision with tunica vaginalis flap (TVF) coverage may salvage a testis that would otherwise be lost. The technique addresses testicular compartment syndrome — elevated intratesticular pressure from ischemia-induced edema that impairs reperfusion even after untwisting the cord.[16][17][18]
Rationale
- Pressure measurements after detorsion alone: 34 mm Hg
- Pressure after tunica albuginea incision: 5 mm Hg (with diastolic 52 mm Hg — restoring perfusion pressure gradient)[18]
- The tunica albuginea behaves like a non-compliant compartment; decompression allows the swollen parenchyma room to expand and reperfuse
Technique
- Detorse the testis; observe 10–20 min
- If still dusky with questionable viability, make a longitudinal incision in the tunica albuginea on the anterior or lateral surface
- The testis often blushes pink dramatically within minutes as the compartment decompresses
- Harvest a tunica vaginalis flap — raised from the hemiscrotum
- Cover the exposed seminiferous tubules with the TVF, sewing its edges to the remaining tunica albuginea with fine absorbable suture (5-0 or 6-0)
- Proceed with orchiopexy
Outcomes
- Figueroa 2012 comparative study: orchiectomy rate reduced from 35.9% → 15% after introduction of TVF technique (P<0.05)[16]
- Kim 2025 systematic review: TVF effective at preserving testicular volume (≥50%) and preventing orchiectomy in selected cases[17]
- Animal studies show mixed histopathologic results — pressure reduction is real but does not always translate to better tubular preservation
TVF is not a routine step — it is a salvage maneuver when detorsion alone leaves a non-viable-appearing testis and the alternative is orchiectomy.
Outcomes and Complications
Testicular atrophy
- ~56.6% of salvaged testes develop atrophy long-term
- Median volume loss 57.4%[19]
- Risk factors: age <6, delayed surgery, intraoperative evidence of poor perfusion
- Most atrophy manifests at 3–6 months → first scheduled follow-up US at this interval
Compensatory contralateral hypertrophy
The unaffected testis undergoes compensatory enlargement in both orchiopexy and orchiectomy groups — a normal physiologic response.
Fertility
- Abnormal semen parameters are common after unilateral torsion, even with successful salvage
- Mechanism: ischemia-reperfusion injury, germ cell apoptosis, antisperm antibody formation, hypothalamic-pituitary-gonadal axis disruption[5]
- Counsel adolescent and adult patients about potential subfertility; consider sperm banking in carefully selected older adolescents before surgery if operative delay is prolonged
Recurrent torsion — even after fixation
Despite properly performed orchiopexy, ~4.5% recurrence rate over 10+ year follow-up:[13]
- Can occur 0.5 to 23 years after initial fixation (mean ~7 years)
- Both ipsilateral and contralateral testes are at risk of recurrent torsion
- Occurs even with nonabsorbable polypropylene sutures
- Patients should be counseled that orchiopexy reduces but does not eliminate risk — any new acute scrotal pain warrants immediate evaluation
Neonatal torsion — a special case
Neonatal (first year of life) torsion is typically extravaginal — the entire tunica vaginalis twists with the cord, rather than the testis twisting within the tunica. Often diagnosed at birth or in early infancy with a firm, discolored hemiscrotum and a testis already non-viable at presentation. Management is debated:
- Some advocate urgent exploration with contralateral orchiopexy
- Others advocate elective exploration at 6 months (low salvage rate of affected testis; avoid neonatal GA risk)
- Asymptomatic metachronous contralateral torsion has been reported in the neonate — supporting the case for exploration
Counseling
Essential preoperative and discharge elements:
- Bilateral orchiopexy is part of every torsion operation; explain why
- Salvage is time-dependent — emphasize that hours matter and revisit the timeline with the patient and family
- Possibility of orchiectomy if the testis is non-viable — consent for this preoperatively
- Atrophy is common even after successful salvage; 3–6 month follow-up ultrasound
- Fertility implications — abnormal semen parameters possible; sperm banking considered in selected cases
- Recurrence risk ~5% long-term — any future acute scrotal pain → immediate re-evaluation
Differential Diagnosis — Acute Scrotum
| Diagnosis | Key distinguishing features |
|---|---|
| Testicular torsion | Severe acute pain, absent cremasteric reflex, high-riding testis, TWIST ≥5 |
| Torsion of the appendix testis | Blue dot sign at superior testis pole; normal cremasteric reflex; localized tenderness at upper pole |
| Epididymitis / epididymo-orchitis | Gradual onset, dysuria, fever, positive Prehn sign (pain relief with elevation), normal cremasteric reflex |
| Incarcerated inguinal hernia | Groin mass extending into scrotum; GI symptoms |
| Hydrocele with acute rupture/bleed | Transillumination + ultrasound differentiates |
| Fournier's gangrene | Systemic toxicity, crepitus, necrotizing skin signs |
| Henoch-Schönlein purpura | Purpuric skin lesions; may have scrotal involvement mimicking torsion |
See Also
References
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2. Lacy A, Smith A, Koyfman A, Long B. High risk and low prevalence diseases: testicular torsion. Am J Emerg Med. 2023;66:98–104. doi:10.1016/j.ajem.2023.01.031
3. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835–40.
4. Ebell MH. Clinical diagnosis of testicular torsion. Am Fam Physician. 2022;106(6):712–713.
5. Elsayed Abouzed DE, Bafail DA, Refaie SM, et al. Pathophysiology and impact of testicular torsion/detorsion on male reproduction: therapeutic approach with some phytochemicals. Fitoterapia. 2025;185:106722. doi:10.1016/j.fitote.2025.106722
6. Karaguzel E, Kadihasanoglu M, Kutlu O. Mechanisms of testicular torsion and potential protective agents. Nat Rev Urol. 2014;11(7):391–9. doi:10.1038/nrurol.2014.135
7. Prater JM, Overdorf BS. Testicular torsion: a surgical emergency. Am Fam Physician. 1991;44(3):834–40.
8. Qin KR, Qu LG. Diagnosing with a TWIST: systematic review and meta-analysis of a testicular torsion risk score. J Urol. 2022;208(1):62–70. doi:10.1097/JU.0000000000002496
9. Hsu CT, Chiu PW. Successful outcome of manual testicular detorsion using point-of-care ultrasound guidance: a clinical experience. Pediatr Emerg Care. 2023;39(10):813–815. doi:10.1097/PEC.0000000000003048
10. Cost NG, Bush NC, Barber TD, Huang R, Baker LA. Pediatric testicular torsion: demographics of national orchiopexy versus orchiectomy rates. J Urol. 2011;185(6 Suppl):2459–63. doi:10.1016/j.juro.2011.01.016
11. Bowlin PR, Gatti JM, Murphy JP. Pediatric testicular torsion. Surg Clin North Am. 2017;97(1):161–172. doi:10.1016/j.suc.2016.08.012
12. Koh YH, Granger J, Cundy TP, Boucaut HA, Goh DW. Sutured point-fixation versus Jaboulay fixation for salvaged testicular torsion in children. J Pediatr Surg. 2019;54(12):2631–2635. doi:10.1016/j.jpedsurg.2019.08.018
13. Mor Y, Pinthus JH, Nadu A, et al. Testicular fixation following torsion of the spermatic cord — does it guarantee prevention of recurrent torsion events? J Urol. 2006;175(1):171–3. doi:10.1016/S0022-5347(05)00060-1
14. Kozminski DJ, Kraft KH, Bloom DA. Orchiopexy without transparenchymal fixation suturing: a 29-year experience. J Urol. 2015;194(6):1743–7. doi:10.1016/j.juro.2015.06.089
15. Lent V, Stephani A. Eversion of the tunica vaginalis for prophylaxis of testicular torsion recurrences. J Urol. 1993;150(5 Pt 1):1419–21. doi:10.1016/s0022-5347(17)35795-6
16. Figueroa V, Pippi Salle JL, Braga LH, et al. Comparative analysis of detorsion alone versus detorsion and tunica albuginea decompression (fasciotomy) with tunica vaginalis flap coverage in the surgical management of prolonged testicular ischemia. J Urol. 2012;188(4 Suppl):1417–22. doi:10.1016/j.juro.2012.02.017
17. Kim J, Lorenzo A, Rivera KC, et al. Effectiveness of tunica albuginea incision and tunica vaginalis flap for testicular torsion: a systematic review. World J Urol. 2025;43(1):246. doi:10.1007/s00345-025-05638-w
18. Kutikov A, Casale P, White MA, et al. Testicular compartment syndrome: a new approach to conceptualizing and managing testicular torsion. Urology. 2008;72(4):786–9. doi:10.1016/j.urology.2008.03.031
19. Yu CJ, Zhao J, Luo J, et al. Long-term follow-up results of testicular torsion in children. Asian J Androl. 2022;24(6):653–659. doi:10.4103/aja2021127