Twisting of the spermatic cord — surgical emergency; salvage rate falls rapidly after 6 hours of ischemia.
Also known as: testicular torsion, spermatic cord torsion, torsion
Overview
Twisting of the spermatic cord causing compromise of testicular blood flow. Two anatomic subtypes: intravaginal (within tunica vaginalis; most common, due to 'bell-clapper' deformity) and extravaginal (entire testis and tunica twist; characteristic of neonates).
Epidemiology
Annual incidence ~1 in 4,000 males under 25 years. Bimodal peaks: neonatal (extravaginal) and adolescent (12-18 years; intravaginal). Accounts for ~10-15% of acute scrotum presentations.
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Testicular tumor — Painless mass; can present with acute pain if hemorrhage; ultrasound
Varicocele (acute) — 'Bag of worms,' more on left; usually painless or dull ache
Diagnostic workup
Diagnostic criteria
Clinical diagnosis when classic — proceed directly to surgical exploration. Ultrasound for equivocal presentations.
Labs
Urinalysis — typically negative (pyuria favors epididymitis)
CBC, BMP, type and screen if surgical exploration planned
Imaging
Color Doppler ultrasound — first-line imaging when diagnosis uncertain; shows decreased or absent blood flow in affected testis; sensitivity ~88-95%
DO NOT delay surgical exploration for imaging if clinical suspicion is high
TWIST score (Testicular Workup for Ischemia and Suspected Torsion): 0-2 low risk, 3-4 intermediate (US needed), 5-7 high risk (proceed to OR)
Diagnostic algorithm
flowchart TD
A[Acute scrotal pain<br/>± nausea, vomiting] --> B[Focused exam:<br/>cremasteric reflex,<br/>testis lie, tenderness,<br/>Prehn sign]
B --> C{High clinical<br/>suspicion for torsion?}
C -->|High TWIST 5-7<br/>or classic exam| D[Urology STAT —<br/>OR for detorsion +<br/>bilateral orchiopexy]
C -->|Intermediate<br/>TWIST 3-4| E[Color Doppler US]
E -->|Decreased/absent flow| D
E -->|Normal flow| F[Consider epididymitis,<br/>torsion of appendix,<br/>other causes]
C -->|Low TWIST 0-2| F
D --> G{Testis viable?}
G -->|Yes| H[Detorse + bilateral<br/>orchiopexy 3-point fixation]
G -->|No| I[Orchiectomy +<br/>contralateral orchiopexy]
F --> J[Treat per diagnosis<br/>± antibiotics, NSAIDs,<br/>follow-up]
Acute scrotum algorithm — high suspicion goes directly to OR; do not delay surgery for imaging.
Treatment
First-line
Emergent surgical exploration — do not delay for imaging if clinical picture is classic
Time from onset to detorsion is the key prognostic factor
Manual detorsion may be attempted as temporizing measure: 'open book' technique — rotate testis laterally (outward) for affected side (most torsions are medial); 1.5-2 full turns; relief of pain and descent of testis indicate success — DOES NOT replace surgery
Surgical detorsion + bilateral orchiopexy (3-point fixation of both testes to scrotal wall to prevent recurrence)
Orchiectomy if testis is nonviable after detorsion and brief observation
Neonatal torsion (extravaginal)
Often diagnosed in utero or at birth — firm, dark, fixed scrotal mass
Affected testis is usually nonviable
Surgical management is controversial — some recommend prompt exploration with orchiopexy of contralateral side to prevent asynchronous torsion
Bilateral exploration during the same procedure is standard
Intermittent torsion
Recurrent self-resolving episodes of similar pain
Even if testis appears normal between episodes, elective bilateral orchiopexy is recommended
Highest risk for future complete torsion
Torsion of appendix testis (mimic)
Usually pre-pubertal boys
Localized upper-pole tenderness, 'blue dot sign' through skin
Cremasteric reflex preserved
Doppler shows normal testicular flow
Conservative management: NSAIDs, rest; self-resolves in 5-10 days
Complications
Loss of testis (orchiectomy)
Subfertility / infertility — even after successful detorsion, sympathetic effects on contralateral testis can impair spermatogenesis
Testicular atrophy after delayed detorsion
Recurrent torsion if orchiopexy not performed
Psychological impact on adolescent body image
PANCE pearls
Testicular torsion is a SURGICAL EMERGENCY — call urology immediately and do not delay surgery for imaging if the diagnosis is clinically apparent.
Salvage rate is >90% if detorsion occurs within 6 hours; <50% by 12 hours; <20% by 24 hours.
Always examine the scrotum in any boy or young man with abdominal or groin pain — torsion can present with referred pain.
Absent cremasteric reflex on the affected side is the most sensitive clinical finding for torsion in adolescents.
Manual detorsion is rotated like 'opening a book' (laterally/outward) — but this is only a temporizing measure; surgical orchiopexy is still required.
Bilateral orchiopexy at surgery is standard — bell-clapper deformity is usually bilateral.
Suspect torsion in any neonate with a firm, discolored hemiscrotum from birth; in this age group most testes are nonviable, but contralateral fixation is important.
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