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The amount of testicular damage is related to the degree and

duration of venous and arterial obstruction. If pain has been

present for <6 hours, the testicular salvage rate is 80-100%.

• When considering testicular torsion as a diagnosis,

never al low an imaging study or laboratory test to delay

an emergent urologic consultation.

• When attempting manual detorsion, remember the

direction to turn the testicle is like opening a book.

CLINICAL PRESENTATION

..... History

Abnormal development of the fixation of the tunica vaginalis to the posterior scrotal wall can cause the t esticle to

hang freely in the scrotum like the clapper of a bell, aligned

in a horizontal rather than vertical axis (Figure 41-1). This

predisposes the testicle to torse, frequently in the context of

strenuous physical activity or scrotal t rauma. Torsion can

also occur during sleep, when the cremaster muscle con ­

tracts. Other risk factors for testicular torsion include

incomplete descent of the testes and testicular atrophy.

Patients will present with acute onset of unilateral scro ­

tal pain. The pain is usually severe and noted in the lower

abdomen, the inguinal canal, or the testis. Nausea and

vomiting are often associated. Because it is an ischemic

vascular event, the pain is not positional initially. Later,

with significant testicular and scrotal edema, the pain may

become more positional.

..... Physical Examination

Examination of the opposite testis may be helpful because

anatomic abnormalities are often bilateral. Examine the

patient in both the supine and standing positions. When

the patient is standing, look for the affected testicle to be

aligned in a horizontal (bell-clapper deformity) rather

1 74

TESTICULAR TORSION

Twisted spermatic -....lUi"-'"'""

cord

Testicle in

horizontal -�t'hl�,:.;...­

plane

Figure 41-1 . Bel l-clapper deformity. Reprinted with

permission from Bondesson J D. Chapter 8. Urologic

Conditions. In: Knoop KJ, Stack LB, Storrow AB, Thurman

RJ, eds. The Atlas of Emergency Medicine. 3 rd ed. New

York: McGraw-Hill, 201 0.

than vertical axis (normal). The involved testicle will often

lie higher in the scrotum than the opposite side.

The involved testicle will be firm, swollen, tender, and the

scrotmn will usually be edematous. The size of the scrotal

mass is an unreliable indicator of the underlying etiology,

and the examination may occasionally be unremarkable.

Prehn sign (relief of pain with elevation and support of

the scrotmn) is more indicative of epididymo-orchitis than

testicular torsion; however, this distinction is unreliable.

The cremasteric reflex is tested by lightly scratching the

inner aspect of the thigh. A positive reflex is elicited when

the ipsilateral testicle retracts upward. This reflex may be

normally absent in infants and toddlers, however, absence

of this reflex is relatively specific for torsion.

DIAGNOSTIC STUDIES

.... Laboratory

Urinalysis will usually be normal. Complete blood count

most often reveals an absence of a leukocytosis.

.... Imaging

Color Doppler ultrasound is the preferred diagnostic study

and has a sensitivity of 85-100% and a specificity of 100%.

Ultrasound is also helpful for diagnosing other conditions

that are part of the differential diagnosis of t orsion, such as

epididymitis, torsion of a testicular appendage, testicular

rupture, hydrocele, hematocele, or hernia.

Nuclear radioisotope scanning has similar sensitivity to

ultrasound; however, the specificity of nuclear scans is

much lower. In addition, nuclear scans are more tirneconsmning than ultrasound.

MEDICAL DECISION MAKING

Testicular torsion is a time-sensitive condition that can

result in loss of the testicle with associated loss of fertility.

Therefore, assmne acute testicular pain is torsion until

proven otherwise.

Perform a focused history and physical examination as

soon as possible. If your clinical suspicion for torsion is

high, obtain an immediate urology consult and attempt

manual detorsion.

Factors associated with testicular torsion include abrupt

onset of pain, pain for less than 24 hours at the time of

presentation, nausea and vomiting, high position of the

testis, and abnormal cremasteric reflex. Torsion of a testicular appendage typically presents as pain that is more

localized to one point on the testicle, more gradual in

onset, and without nausea and vomiting. These small

developmental remnants may be located at various positions on the testicle and on exam may be palpable as a hard

tender nodule, most often at the upper pole of the testicle.