AKT · Renal & urology/Scrotum & male GU

Testicular torsion

Twisting of the spermatic cord → testicular ischaemia (a urological emergency)

Overview

Twisting of the spermatic cord cutting off the testicular blood supply — a surgical EMERGENCY because the testis infarcts within hours. It classically affects adolescents/young men with sudden severe unilateral testicular pain. The single most important rule: it is a clinical diagnosis and surgical exploration must NOT be delayed for imaging — salvage falls sharply after ~6 hours.

Recognise

Sudden severe unilateral testicular/lower-abdominal pain, often with nausea/vomiting; adolescent/young man (can be neonatal)
High-riding, horizontal-lying, exquisitely tender testis; absent cremasteric reflex; pain NOT relieved by elevation (negative Prehn's sign)
May follow trauma/exertion or occur spontaneously (bell-clapper deformity)

Red flags

It is a CLINICAL diagnosis → immediate surgical exploration; do NOT delay for an ultrasound — the testis infarcts within ~6 hours
Any acute scrotum in a young male is torsion until proven otherwise

Differentials & how to tell them apart

Epididymo-orchitisgradual onset, fever, dysuria/discharge, positive Prehn's sign (pain eased by elevation), present cremasteric reflex — but never let it delay exploration if torsion is possible

Torsion of a testicular appendage (hydatid of Morgagni)'blue dot' sign, more localised, younger boys

Strangulated hernia / incarceratedgroin/scrotal swelling — surgical assessment

Testicular torsion — abnormal testicular perfusion on scrotal ultrasound
Chee-Wai Mak & Wen-Sheng Tzeng / CC BY 3.0 — Wikimedia Commons

Investigations

Clinical diagnosis — go straight to theatre if suspected. Doppler ultrasound (reduced/absent flow) ONLY if it will not delay surgery and the diagnosis is genuinely in doubt; urine dip (often normal — helps consider epididymo-orchitis).

Management

Immediate surgical exploration + bilateral orchidopexy (do NOT delay for imaging)

1Treat any acute scrotum in a young male as torsion: it is a CLINICAL diagnosis → immediate surgical exploration. Do NOT wait for an ultrasound.Gate: Salvage falls sharply after ~6 hours — never delay theatre for imaging; if explored, perform BILATERAL orchidopexy (the bell-clapper deformity is usually bilateral).
2Untwist and fix a viable testis (orchidopexy) or remove a non-viable one (orchidectomy), and fix the contralateral side.

IMMEDIATE surgical exploration + bilateral orchidopexy — untwist and fix; fix the contralateral testis too (the predisposing deformity is usually bilateral)

Orchidectomy if non-viable — remove an infarcted testis at exploration

Analgesia + keep nil by mouth — prepare for theatre; do not delay

Manual detorsion only as a temporising measure — if surgery is delayed — does not replace exploration

Key points

Sudden severe testicular pain + high-riding horizontal testis + absent cremasteric reflex + NEGATIVE Prehn's (elevation doesn't help) = torsion → STRAIGHT to theatre, do NOT delay for ultrasound (infarcts by ~6 h). Bilateral orchidopexy. Epididymo-orchitis (gradual, fever, positive Prehn's) is the main mimic — but explore if in doubt.

Monitor & prognosis

Operative viability/outcome; post-op recovery.

Excellent if explored within ~6 hours; testicular loss rises sharply with delay.

Source: BAUS; cross-ref surgery (acute scrotum)