Testicular Torsion

What happens in testicular torsion

Each testicle hangs from the spermatic cord, which carries its blood vessels and the vas deferens. Normally, tissue attachments anchor the testicle to the scrotum. Some people have a "bell clapper" deformity, in which the testicle is not well anchored and can rotate freely, often on both sides. When the testicle twists, veins are compressed first, causing swelling, then arteries, cutting off blood supply. Without blood, testicular tissue starts dying within hours.

Symptoms

• sudden, severe pain in one testicle, often waking the person from sleep or starting after activity or minor injury
• swelling and redness of the scrotum
• nausea and vomiting
• pain in the lower belly or groin
• the testicle sits higher than usual or at an unusual angle
• absent cremasteric reflex (stroking the inner thigh does not lift the testicle)
• sometimes fever and frequent urination

Some boys are embarrassed and report only belly pain. Any boy with sudden lower abdominal pain should have his testicles examined.

Torsion vs other causes of testicle pain

Because it is hard to tell these apart quickly, sudden testicle pain is treated as torsion until proven otherwise.

Diagnosis

A urologist or emergency doctor diagnoses torsion by examination. Scoring systems (such as the TWIST score) help estimate risk. Doppler ultrasound shows reduced or absent blood flow, but if the diagnosis is clear, surgery should not be delayed for imaging.

Treatment

Emergency surgery

• the testicle is exposed through a small incision in the scrotum, untwisted, and checked for viability
• if viable, it is stitched to the scrotal wall (orchiopexy) to prevent recurrence
• the other testicle is also fixed, because the same anatomy is usually present on both sides
• if the testicle is dead, it is removed (orchiectomy); a prosthetic testicle can be placed later

Manual detorsion

A doctor may try to untwist the testicle by hand (usually rotating outward, "opening the book") to restore blood flow while surgery is arranged. Surgery is still needed.

Outcomes and timing

After surgery

• rest for a few days; avoid strenuous activity and sports for 2 to 4 weeks, or as advised
• pain relief with acetaminophen (paracetamol) or ibuprofen at the label dose
• supportive underwear and ice packs for swelling

Fertility and testosterone are usually normal with one healthy testicle, although some studies show modest effects on sperm counts after torsion.

Frequently asked questions

What are the symptoms of testicular torsion?

The main symptom is sudden, severe pain in one testicle, often with swelling, redness, nausea and vomiting. The testicle may sit higher than normal or at an odd angle. Some boys feel pain mainly in the lower belly or groin.

How long do you have to fix testicular torsion?

Time is critical. If surgery restores blood flow within about 6 hours, the testicle can usually be saved. After 12 hours, the chance drops sharply, and after 24 hours most testicles are lost. Go to the ER immediately.

Can testicular torsion go away on its own?

Sometimes the testicle untwists by itself, and pain suddenly improves. This is called intermittent torsion. It can happen again, so a urologist should evaluate it promptly. Surgery to fix both testicles prevents future episodes.

What is the difference between testicular torsion and epididymitis?

Torsion causes sudden, severe pain and is a surgical emergency. Epididymitis is an infection or inflammation that causes pain developing over days, often with burning urination or fever, and is treated with antibiotics. Because they overlap, sudden pain should be checked urgently.

Can testicular torsion affect fertility?

Most people who lose or have damage to one testicle still have normal fertility and testosterone from the other. Prompt surgery protects the affected testicle and fixes the other one to prevent torsion on that side.