18-year-old Arthur comes to the emergency department complaining of sudden onset pain in his testicles that woke him up at 4 am.
Arthur had noticed that part of his testicle appeared swollen when he awoke. This concerned him, since he didn’t remember an injury. He tried applying ice, but after a while of no relief, his parents drove him to the local ED. His pain has increased and is now (at 7 am), a 10/10.
Arthur has never experienced this pain before and wonders if the stomach bug he had last week could have contributed.
The 5Ws + H of Testicular Torsion
What is it?
To understand torsion, we need to know testicular anatomy.
The testes sit in the scrotum, suspended by their respective spermatic cords. The cords run through the inguinal canal. The testes are not, however, freely suspended. They normally attach at various points to the inner layer of the scrotum through the tunica vaginalis, a layer of peritoneum.1
Despite these attachment sites, the very nature of this ‘ball-on-rope’ structure increases the risk of twisting, also known as torsion. Some testicles are less firmly attached resulting in the Bell Clapper Deformity.1 This makes some boys and men more likely to develop testicular torsion.
Why is torsion such a problem?
Aside from severe pain, torsion can affect the vascular supply causing ischemia and venous congestion.2,3
The major testicular blood vessels are:
- Testicular artery
- Deferential artery – runs alongside the vas deferens
- Cremasteric artery – supplies the cremasteric muscle that surrounds the inside of the inguinal canal and scrotum
- Pudendal artery (NOT within the spermatic cord) – supplies the scrotal wall
The pampiniform plexus of veins drain the testicular blood supply.
Who gets it?
Consider testicular torsion in any male patient presenting with lower abdominal pain or testicular pain or swelling. However, torsion is most prevalent in the pediatric population.4
Where are the clinical features?
The history of testicular torsion may involve recent trauma or vigorous activity. The torsion may also be spontaneous, often occurring in the middle of night.
Physical exam findings can assist with the diagnosis.
Begin with visual inspection of the testes, looking for swelling and erythema. This can suggest torsion, but may also be present in epididymitis or epididymo-orchitis.
Palpate the testes and look for isolated tenderness at the superior pole. This is highly specific for torsion.5 Tenderness posteriorly can suggest epididymitis.1
Feel for testicular lie. The long axis of the testis normally sits vertically in the scrotum. The tension from torsion pulls the testis up so it lies ‘sideways’ with the long axis being horizontal. This produces an asymmetrically high riding testis.
Next, check for the cremasteric reflex by lightly stroking the superior part of the medial thigh. This normally causes contraction of the cremasteric muscle that runs along the inside of the inguinal canal and scrotum, pulling up the ipsilateral testis. Absence of this reflex is the most sensitive and specific finding for testicular torsion.1,5
Table 1: Comparison of Testicular Torsion, Epididymitis, and Torsion of Testicular Appendix
|Testicular Torsion||Epididymitis||Torsion of Testicular Appendix|
|Etiology||May occur after trauma or spontaneously.||Most commonly infectious (chlamydia, gonorrhea) etiology. In pre-pubertal boys consider viral etiology.||Occurs spontaneously. Predisposed to torsion due to pedunculated shape.|
|Can also be caused by trauma, or autoimmune conditions.|
|Clinical Presentation||Sudden onset on pain.||Gradual onset of pain.||Sudden onset of pain.|
|Significant, generalized testicular swelling.||Pain or swelling located in posterior aspect of testes.||Pain located at the anterior superior pole of the testes.|
|Lower urinary tract symptoms, fevers and discharge may be present.|
|Special Signs||Negative cremasteric reflex.||Manual elevation of scrotum relieves pain (Prehn sign).||Blue dot sign.|
|Positive Bell-clapper deformity.||Positive cremasteric reflex|
What about imaging?
Ultrasound is the definitive method for diagnosing testicular torsion. It is 93% sensitive and 100% specific in experienced hands.3 In the long axis ultrasound, the normal testicle is an oval, homogenous structure with smooth borders. It may look more circular in the short axis. Use both color and power Doppler starting with the unaffected testicle to establish a baseline.3 Then assess the affected testicle.
Consider using the TWIST Score:
- Presence of testicular swelling
- Presence of a hard testicle
- Absence of the cremasteric reflex
- Presence of a high-riding testicle
- Presence of nausea/vomiting
Each feature is awarded one point.
- A score of 0-2 is considered low risk and has a high negative predictive value for torsion. Therefore, no further imaging or surgical consultation is required.
- A score of 3-4 is considered intermediate risk and warrants imaging such as an ultrasound.
- A score of 5-6 is considered high risk, and has a high positive predictive value for torsion. An ultrasound is not required for diagnosis. Surgical consultation in this case is required.1
When does irreversible damage occur?
After 8 hours of torsion, irreversible damage is more likely to be present.6
How do we fix it?
Torsion is a surgical emergency! The first step in management of testicular torsion is referral to urology for surgical detorsion and fixation of the testicle.
If urology is not available immediately, manual detorsion should be attempted.4 Manual detorsion is as easy (or as difficult) as opening a book. Most torsions occur due to medial twisting. Therefore, to detorse, you must twist the testicle laterally as though you are opening the pages of a book. This manoeuvre should produce relief of pain, confirming the presence of torsion.
Back to the case:
Fortunately for Arthur, a urologist Dr. Brian was present at the time of his presentation to the ED. As Arthur had not passed the 12-hour window, he underwent immediate surgical detorsion and was back home several hours later.
This post was copyedited and uploaded by Kimberly Vella.
- 1.Barbosa JA, Tiseo BC, Barayan GA, et al. Development and Initial Validation of a Scoring System to Diagnose Testicular Torsion in Children. Journal of Urology. May 2013:1859-1864. doi:10.1016/j.juro.2012.10.056
- 2.Pentyala S, Lee J, Yalamanchili P, Vitkun S, Khan SA. Testicular Torsion: A Review. J Low Genital Tract Dis. January 2001:38-47. doi:10.1046/j.1526-0976.2001.51008.x
- 3.Schick M, Sternard B. Testicular Torsion. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448199/. Published January 2019.
- 4.Molokwu CN, Somani BK, Goodman CM. Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients. BJU International. September 2010:990-993. doi:10.1111/j.1464-410x.2010.09557.x
- 5.Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion? J Fam Pract. 2009;58(8):433-434. https://www.ncbi.nlm.nih.gov/pubmed/19679025.
- 6.Wampler SM, Llanes M. Common Scrotal and Testicular Problems. Primary Care: Clinics in Office Practice. September 2010:613-626. doi:10.1016/j.pop.2010.04.009
Reviewing with the Staff
Testicular torsion is a surgical emergency, and time is testicle!
This article provides a great summary to facilitate the diagnosis and treatment of torsion. What’s most important to remember is that we must think of testicular torsion any time a male patient presents with testicular or lower abdominal pain. If you suspect torsion, go ahead and order your testicular ultrasound, but call your urology consultant at the same time. Because testicular torsion quickly results in ischaemia and, ultimately, death of testicular tissue, it’s important not to wait for the results of your ultrasound.
If you need to attempt a manual detorsion, you can use bedside ultrasound to help you out. You should be able to see the ovoid shape of the testicle convert from horizontally-oriented to vertically-oriented. If you use colour Doppler, you should be able to see improvement in blood flow into and out of the testicle as you achieve detorsion. Ultimately, your patient’s pain is the best indicator of a successful detorsion. Though most testicles are twisted medially and require lateral detorsion, if this is not successful, try twisting medially, as a small percentage of torsions are actually lateral.