Testicular Torsion



Eugene Minevich, MD, Assistant Professor, Department of Surgery, Division of Pediatric Urology, University of Cincinnati

Nothing to disclose.

Leslie Tackett McQuiston, MD, FAAP, Assistant Professor of Surgery (Urology) Dartmouth Medical School; Staff Pediatric Urologist, Dartmouth-Hitchcock Hospital

Nothing to disclose.

Specialty Editor(s)

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine

eMedicine Salary Employment

J Stuart Wolf Jr, MD, FACS, The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

Baxter Healthcare Consulting fee Consulting

Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation

Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine

Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching


Torsion of the testis, or more correctly, torsion of the spermatic cord, is a surgical emergency because it causes strangulation of gonadal blood supply with subsequent testicular necrosis and atrophy. Acute scrotal swelling in children indicates torsion of the testis until proven otherwise. In approximately two thirds of patients, history and physical examination are sufficient to make an accurate diagnosis.

History of the Procedure

Patients often complain of acute-onset scrotal discomfort, which may occur at rest or may relate to sports or physical activities. They may describe similar previous episodes, which may suggest intermittent testicular torsion.[1] Patients deny voiding problems or painful urination but may describe nausea and vomiting.


Testicular torsion refers to twisting of the spermatic cord structures, either in the inguinal canal or just below the inguinal canal. The following are the 2 most common types of testicular torsion (see image below).

View Image

Testicular torsion: (A) extravaginal; (B) intravaginal.





Torsion of the spermatic cord may interrupt blood flow to the testis and epididymis. The degree of torsion may vary from 180-720°. Increasing testicular and epididymal congestion promotes progression of torsion.

The extent and duration of torsion prominently influence both the immediate salvage rate and late testicular atrophy. Testicular salvage most likely occurs if the duration of torsion is less than 6-8 hours. If 24 hours or more elapse, testicular necrosis develops in most patients.


Prenatal torsion manifests as a firm, hard, scrotal mass, which does not transilluminate in an otherwise asymptomatic newborn male. The scrotal skin characteristically fixes to the necrotic gonad.

In older boys, the classic presentation of testicular torsion is the sudden onset of severe testicular pain followed by inguinal and/or scrotal swelling. Pain may lessen as the necrosis becomes more complete. Approximately one third of patients also have gastrointestinal upset with nausea and vomiting. In some patients, scrotal trauma or other scrotal disease (including torsion of appendix testis or epididymitis) may precede the occurrence of subsequent testicular torsion.

A physical examination may reveal a swollen, tender, high-riding testis (see image below). The absence of the cremasteric reflex in a patient with acute scrotal pain supports the diagnosis of torsion. In time, a reactive hydrocele, scrotal wall erythema, and ecchymosis become more striking.

View Image

A 17-year-old teenager with a 72-hour history of scrotal pain.

Differential diagnosis


If clinical evaluation reveals testicular torsion, transfer the patient to the operating room for urgent scrotal exploration, regardless of the number of hours since the onset of presenting symptoms.

Relevant Anatomy

For normal development and sperm production, the testis must descend from its original position near the kidney into the scrotum. Researchers propose that various mechanisms, including gubernacular traction and intra-abdominal pressure, are responsible for testicular descent; however, endocrine factors of the hypothalamic-pituitary-testicular axis also play a major role in this process. Between the 12th and 17th week of gestation, the testis undergoes transabdominal migration to a location near the internal inguinal ring. The testis does not migrate transinguinally to its final position until the seventh month of gestation.

The testes are paired ovoid structures that are housed in the scrotum and positioned so that the long axis is vertical. The anterolateral two thirds of the organ is free of any scrotal attachment. The epididymis, connective tissue, and vasculature cover the posterolateral aspect of the organ. The capsule of the testis is termed the tunica albuginea.

Laboratory Studies

Imaging Studies

Medical Therapy

Manual detorsion of the torsed testis may be attempted but is usually difficult because of acute pain during manipulation. This nonoperative detorsion is not a substitute for surgical exploration. If successful (ie, confirmed by color Doppler sonogram in a patient with complete resolution of symptoms), perform definitive surgical fixation of the testes before the patient leaves the hospital as an urgent—rather than emergent—procedure.

A recent study has shown that the use of nicotinamide may successfully decrease ischemia-reperfusion injury in early and late periods in both testicles.[2]

Surgical Therapy

Treatment of testicular torsion varies according to patient age.

Intraoperative Details

Signs of a viable testis after detorsion (see image below) include a return of color, return of Doppler flow, and arterial bleeding after incision of tunica albuginea.

View Image

Intraoperative findings in testicular torsion.

Postoperative Details


Torsion of the spermatic cord continues to be one of the few emergencies in urologic practice. Delay of more than 6-8 hours between onset of symptoms and the time of surgical (or manual) detorsion reduces the salvage rate to 55-85%. A correlation may exist between the duration of torsion and abnormal semen parameters, and some authorities suggest that retention of an injured testis can induce pathologic changes to the contralateral testis.

Outcome and Prognosis

Success in the management of spermatic cord torsion is measured by immediate testicular salvage and incidence of late testicular atrophy, which are, in turn, directly related to the duration and degree of testicular torsion. Delaying surgical intervention worsens the intraoperative testicular salvage and incidence rate and the extent of subsequent testicular atrophy. The delay between the onset of symptoms and the time of surgical or manual detorsion is obviously of utmost importance in achieving a viable testis.

Future and Controversies

Recent studies show that exocrine and endocrine function is substandard in men with a history of unilateral torsion. The following 3 theories explain the contralateral disease noted in torsion:

To explain the decreased fertility observed in unilateral torsion of the spermatic cord, several specialists suggest an autoimmune mechanism. This hypothesis is based upon the following:


  1. Johnston BI, Wiener JS. Intermittent testicular torsion. BJU Int. May 2005;95(7):933-4.[View Abstract]
  2. Kar A, Ozden E, Yakupoglu YK, Kefeli M, Sarikaya S, Yilmaz AF. Experimental unilateral spermatic cord torsion: the effect of polypolymerase enzyme inhibitor on histopathological and biochemical changes in the early and late periods in the ipsilateral and contralateral testicles. Urology. Aug 2010;76(2):507.e1-5.[View Abstract]
  3. Sun J, Liu GH, Zhao HT, Shi CR. Long-term influence of prepubertal testicular torsion on spermatogenesis. Urol Int. 2006;77(3):275-8.[View Abstract]
  4. Barada JH, Weingarten JL, Cromie WJ. Testicular salvage and age-related delay in the presentation of testicular torsion. J Urol. Sep 1989;142(3):746-8.[View Abstract]
  5. Brandt MT, Sheldon CA, Wacksman J, Matthews P. Prenatal testicular torsion: principles of management. J Urol. Mar 1992;147(3):670-2.[View Abstract]
  6. Chan JL, Knoll JM, Depowski PL, Williams RA, Schober JM. Mesorchial testicular torsion: case report and a review of the literature. Urology. Jan 2009;73(1):83-6.[View Abstract]
  7. Kalfa N, Veyrac C, Lopez M, Lopez C, Maurel A, Kaselas C, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. Jan 2007;177(1):297-301; discussion 301.[View Abstract]
  8. Kapoor S. Testicular torsion: a race against time. Int J Clin Pract. May 2008;62(5):821-7.[View Abstract]
  9. Kyriazis ID, Dimopoulos J, Sakellaris G, Waldschmidt J, Charissis G. Extravaginal testicular torsion: a clinical entity with unspecified surgical anatomy. Int Braz J Urol. Sep-Oct 2008;34(5):617-23; discussion 623-6.[View Abstract]
  10. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg. Feb 1995;30(2):277-81; discussion 281-2.[View Abstract]
  11. Mor Y, Pinthus JH, Nadu A, Raviv G, Golomb J, Winkler H, et al. Testicular fixation following torsion of the spermatic cord--does it guarantee prevention of recurrent torsion events?. J Urol. Jan 2006;175(1):171-3; discussion 173-4.[View Abstract]
  12. Rabinowitz R, Hulbert WC Jr. Acute scrotal swelling. Urol Clin North Am. Feb 1995;22(1):101-5.[View Abstract]
  13. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. Nov 15 2006;74(10):1739-43.[View Abstract]
  14. Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?. J Fam Pract. Aug 2009;58(8):433-4.[View Abstract]
  15. Smith-Harrison LI, Koontz WW. Torsion of the Testis: Changing Concepts. AUA Updates. 1990;32.

Testicular torsion: (A) extravaginal; (B) intravaginal.

A 17-year-old teenager with a 72-hour history of scrotal pain.

Intraoperative findings in testicular torsion.