Definition
Testicular torsion is a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue.
Torsion of testicular or epididymal appendages (appendix testis, appendix epididymis, or testicular hydatids) can also occur.
Causes and Classification
Most common in ages 12-18 years (peak 13-16 years), but can occur at any age including neonates.
Intravaginal Torsion (Most Common)
- Twisting within the tunica vaginalis
- Associated with 'bell clapper deformity'
- 4-8% caused by trauma
- May have history of self-limiting episodes
Extravaginal Torsion
- Twisting of entire cord including processus vaginalis
- Most common in neonates
- No identified anatomical defect
Predisposing Factors
- Bell-clapper deformity
- Testicular tumour
- Testicles with horizontal lie
- History of undescended testis
- Testicular/scrotal trauma
- Long intra-scrotal spermatic cord
Clinical Features
Testicular Torsion
- Sudden onset severe unilateral pain
- Associated abdominal pain, nausea/vomiting
- Severe tenderness on palpation
- High-riding testis with transverse lie
- Absent cremasteric reflex
- Negative Prehn's sign (no pain relief with elevation)
- Possible history of similar self-limiting episodes
Torsion of Appendix Testis/Epididymis
- Sudden or gradual onset over days
- Pain localized to upper testis/epididymis
- No systemic symptoms
- Early: Palpable nodule at upper pole
- Late: Generalized scrotal edema
- "Blue dot sign" - infarcted appendage visible
- Cremasteric reflex usually present
Key Clinical Pearls
- Most common in under 20s
- Bell-clapper deformity is major risk factor
- Angell's sign: Opposite testis lies horizontally
- Time is testicle! Salvage rates decline after 4-6 hours
Management
Diagnostic Approach
- High clinical suspicion warrants immediate surgical exploration without imaging
- If diagnosis unclear, perform urgent Doppler ultrasound
- Never delay surgery for imaging when torsion strongly suspected
Surgical Treatment
Urgent Surgical Exploration
- Immediate urological consultation required
- Intraoperative detorsion and fixation
- Contralateral orchidopexy to prevent future torsion
- Orchiectomy vs orchidopexy decision based on tissue viability
Manual Detorsion Technique
Emergency Procedure
- Perform if surgical delay anticipated (>1-2 hours)
- Stand at patient's feet, rotate affected testis laterally (like opening a book)
- Usually requires 1-3 full rotations (360° each)
- Success indicated by immediate pain relief
- Still requires definitive surgical fixation
Torsion of Appendix Testis Management
- Scrotal support
- NSAIDs for pain control
- Surgical excision if diagnosis uncertain or severe symptoms
Prognosis
- 0-6 hours: >90% salvage rate
- 6-12 hours: 50-90% salvage rate
- 12-24 hours: 0-50% salvage rate
- >24 hours: <10% salvage rate
- >48 hours: Consistently poor outcomes
Differential Diagnosis
| Condition |
Key Differentiating Features |
| Epididymo-orchitis |
- Gradual onset
- Positive Prehn's sign
- UTI symptoms may be present
- Cremasteric reflex usually intact
|
| Torsion of Appendix |
- Blue dot sign
- Localized upper pole tenderness
- No systemic symptoms
|
| Testicular Trauma |
- Clear history of injury
- Ecchymosis often present
|
| Inguinal Hernia |
- Reducible mass
- Separate from testis
- Cough impulse
|
Clinical Decision Rule
When in doubt, explore! The consequences of missing testicular torsion far outweigh the risks of negative exploration.
Salvage rates drop dramatically after 6 hours of symptoms.