Testicular Torsion
An Emergency in Urology
Prepared for: Ifeanyi Ogidi
Date: July 29, 2025
Objectives
• Understand the pathophysiology and risk factors
• Recognize clinical presentation for early diagnosis
• Review diagnostic approach, including imaging
• Discuss emergent management and outcomes
Definition & Types
• Twisting of the spermatic cord → acute ischemia
• Intravaginal torsion (common in adolescents)
• Extravaginal torsion (neonates)
• Complete vs incomplete torsion (degree of rotation)
Epidemiology
• Incidence: ~1 in 4,000 males <25 yr/year
• Peak age: 12–18 years
• Accounts for 10–15 % of acute scrotum cases
Etiology & Risk Factors
• Bell‑clapper deformity (horizontal lie of testis)
• Inadequate gubernacular fixation
• Trauma or vigorous activity
• Cold weather → cremasteric contraction
Pathophysiology
• Venous congestion occurs first
• Arterial obstruction within hours
• Irreversible ischemia beyond 6–8 hours
• Degree of rotation correlates with salvageability
Clinical Presentation
• Sudden, severe unilateral testicular pain
• Scrotal swelling; high‑riding, transverse testis
• Absent cremasteric reflex
• Nausea and vomiting common
Physical Examination Findings
• High‑riding testis with horizontal lie
• Swollen, tender hemiscrotum
• Negative Prehn sign (no relief on elevation)
• Absent cremasteric reflex on affected side
Differential Diagnosis
• Epididymo‑orchitis
• Torsion of testicular appendage
• Incarcerated inguinal hernia
• Trauma / hematoma
Diagnostic Work‑up
• History & focused physical exam are paramount
• Colour Doppler ultrasound: ↓ / absent flow
• Nuclear scan if ultrasound equivocal (rare)
• Do NOT delay surgery for imaging if high suspicion
Management
• Surgical detorsion & bilateral orchiopexy ASAP
• Goal: operate within 4–6 hours of symptom onset
• Manual detorsion (“open‑book”) as temporizing measure
• If non‑viable: orchiectomy + contralateral fixation
Post‑Operative Care
• Analgesia and scrotal support
• Antibiotics if orchiectomy performed
• Counsel regarding fertility and testicular atrophy risk
• Follow‑up ultrasound or exam as indicated
Prognosis & Complications
• Salvage rates: 90 % (<6 h) → <10 % (>24 h)
• Testicular atrophy and subfertility
• Antisperm antibody formation
• Psychological impact
Key Take‑Home Messages
• Testicular torsion = surgical emergency
• Time‑dependent loss of testis; act on suspicion
• Ultrasound helpful but must not delay OR
• Always fix contralateral testis
Conclusion
• Prompt recognition and intervention are critical.
• Maintaining high index of suspicion saves testes and fertility.
References
• American Urological Association (AUA) Guideline: Acute
Scrotum, 2024
• European Association of Urology (EAU) Paediatric Urology
Guidelines, 2025
• Campbell-Walsh Urology, 13th Edition