Testicular torsion is a twist of the spermatic cord that cuts off blood flow to the testicle, most often in adolescents with a bell clapper deformity. It is a surgical emergency, because the chance of saving the testicle drops sharply after about 6 hours.
Key symptoms
- Sudden, severe pain in one testicle, often waking from sleep or after activity
- Nausea and vomiting
- Lower belly or groin pain, sometimes the only complaint in boys
- Past short episodes of pain that went away on their own
What you find on exam
- High-riding testicle lying horizontally
- Absent cremasteric reflex on the affected side
- Swollen, very tender testicle
- Check the abdomen and both groins for other causes
Tests
- Do not delay surgery for tests when the picture is classic
- Scrotal color Doppler ultrasound: reduced or absent flow, twisted cord (whirlpool sign)
- TWIST score to estimate risk
- Urinalysis, usually normal, helps separate it from epididymitis
Treatment basics
- Emergency urology consult and surgical exploration
- Untwisting and fixation of both testicles (bilateral orchiopexy)
- Orchiectomy if the testicle is not viable
- Manual detorsion, rotating outward like opening a book, while waiting for surgery
- Pain control and nothing by mouth
Red flags
- Sudden scrotal pain with vomiting in a boy or young man
- Absent cremasteric reflex with a high-riding testicle
- Pain lasting more than 6 hours
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; NASEMSO National Model EMS Clinical Guidelines. Written by Making Synapses. Making Synapses is not affiliated with these organizations.