Testicular torsion
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Consultation en clinique ou en téléconsultation, partout au Québec.
Clinical presentation
- Sudden acute scrotal pain (cardinal sign): sudden onset + intense + unilateral + often nocturnal (cremasteric muscle at rest → torsion facilitated) + irradiation to groin + lower abdomen + flank + frequent nausea + vomiting (vagal reflex) + pain may be intermittent (recurrent spontaneous torsion-detorsion - intermittent torsion)
- Physical examination : testicle painful to palpation + ascended (retraction due to shortening of the twisted cord) + horizontalized («bell-shaped» transverse position - classic but inconstant) + scrotal swelling + scrotal erythema (late) + contralateral testicle may also be horizontalized if bilateral fixation anomaly («bell-shaped deformity»)
- Negative Prehn sign in torsion: testicular elevation does NOT improve pain in torsion (unlike in epididymitis where elevation relieves - positive Prehn's sign in epididymitis) → sign of low clinical reliability + do not base surgical decision on this sign alone
- Cremasteric reflex : absent on side of torsion (stimulation of inner thigh → elevation normally of testis on same side) → sensitivity 99 % for torsion if absent + but moderate specificity
- Neonatal (extravaginal) torsion : scrotum hard + painless + colored (bluish or black) at birth + poor prognosis for testicle (necrosis already established)
Differential diagnosis
| Diagnosis | Guiding clinical elements | Echo-Doppler |
|---|---|---|
| Testicular torsion | Sudden onset + adolescent + ascended testicle + absent cremasteric reflex + nausea | Absence or reduction of intra-testicular arterial flow → surgical emergency |
| Epididymitis-orchitis | Progressive onset + adult + fever + leukocyturia + possible STI (chlamydia + gonorrhea) + positive Prehn's sign (elevation relieves) | Increased arterial flow (reactive hypervascularization of the epididymis) |
| Morgagni's hydatid torsion | Children aged 7-12 + less intense pain + bluish spot visible through the scrotal skin («blue spot» - pathognomonic) + testicle not ascended | Normal flow in testis + avascular nodule at apex |
| Strangulated inguinal hernia | Irreducible groin mass + nausea + vomiting + inguinal pain + mostly child | Intestinal loop in inguinal canal → surgical emergency |
| Ourlian orchid | Adolescent + adult + parotitis + fever + late orchitis (3-7 days after parotitis) | Increased flow (inflammatory orchitis) |
| Testicular cancer | Painless hard mass + young adult + may present pain if twisted on tumor | Heterogeneous mass + abnormal vascularization → oncology workup |
Diagnostic approach and surgical decision
- Basic rule: in case of strong clinical suspicion of testicular torsion → go directly to the operating room WITHOUT waiting for the echo-Doppler + a negative surgical exploration (hydatid torsion + epididymitis) is acceptable + but a missed testicular torsion is an irreversible functional catastrophe
- Scrotal Doppler ultrasound: examination of choice if clinical probability is intermediate + or if the picture is atypical → sensitivity 86-100 % + specificity 97-100 % + shows absence or reduction of intratesticular arterial flow + BUT must not delay surgery if clinical probability is high → imaging waiting time = minutes of testicular perfusion lost
- TWIST score (Testicular Workup for Ischemia and Suspected Torsion): hard testicle = 2 pts + nausea/vomiting = 1 pt + absence of cremasteric reflex = 1 pt + scrotal swelling = 2 pts + ascended testicle = 1 pt → score 0-2 = low probability (echo-Doppler) + score 3-4 = intermediate (echo-Doppler) + score ≥ 5 = high probability → direct surgery without echo
Surgical treatment
- Emergency scrotal surgery: scrotal incision + opening of vagina + inspection of testicle + assessment of viability (color + bleeding at albuginea incision)
- Detorsion of the spermatic cord : rotate testicle in opposite direction to torsion → restore perfusion → rewarm + warm compresses × 10-15 minutes
- Bilateral orchidopexy: if the testicle is viable → fixation of the affected testicle + contralateral testicle at 3 points on the albuginea (orchidopexy) → prevention of recurrence + and contralateral torsion (bilateral fixation anomaly in 70 % of cases)
- Orchidectomy: if the testicle is non-viable (black + absence of bleeding) → removal of the necrotic testicle → prevent autoimmune reaction against the contralateral testicle (anti-spermatozoa) → contralateral orchidopexy in the same operative timeframe
- Manual untwisting (emergency maneuver while waiting for surgery): outward rotation of testicle («opening a book») × 1.5 turns → may transiently restore perfusion + reduce pain + DO NOT replace surgery + DO NOT delay transfer to emergency room to attempt manual detorsion
Call 911 or go IMMEDIATELY to the emergency room if intense + sudden + unilateral testicular or scrotal pain appears in a teenager or young man - especially if accompanied by nausea + vomiting + or if the testicle seems to be pulled up. Do not wait for the pain to pass. Do not consult a primary care clinic - go straight to the emergency department of a hospital with a urological surgery service. Every minute counts: the testicle can be saved if surgery is performed within 6 hours. Clinique Omicron can carry out the initial assessment and ensure urgent transfer to hospital if necessary. To make an appointment for a post-surgery follow-up or prevention consultation, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners (NPs) recognize the clinical presentation of testicular torsion and immediately refer for emergency surgery without unnecessary diagnostic delay, assess recurrent intermittent torsion (spontaneously resolving transient scrotal pain) and refer to urology for elective prophylactic orchidopexy, provide post-operative follow-up after orchidopexy or orchiectomy, and educate adolescents and their families about warning signs requiring immediate urgent consultation. Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of an emergency physician or urologist. Testicular torsion is an absolute surgical emergency - every minute of delay reduces the chances of saving the testicle. Never wait for sudden acute testicular pain in an adolescent or young man to disappear spontaneously - go immediately to the emergency room.
Omicron Clinic
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En clinique ou en télémédecine, partout au Québec.
Reçus pour assurances. Téléconsultation 7 j/7. Sans médecin de famille requis.