Testicular torsion
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 in Prehn's sign during 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 torsion (extravaginal): scrotum hard + painless + colored (bluish or black) at birth + poor prognosis for testicle (necrosis already established)
Differential diagnosis
| Diagnosis | Clinical clues | Doppler ultrasound |
|---|---|---|
| Testicular torsion | Brutal onset + adolescent + ascended testicle + absent cremasteric reflex + nausea | Absence or reduction of intra-testicular arterial flow → surgical emergency |
| Epididymo-orchitis | Gradual onset + adult + fever + pyuria + possible STI (chlamydia + gonorrhea) + positive Prehn's sign (elevation relieves) | Increased arterial flow (reactive hypervascularization of the epididymis) |
| Torsion of the hydatid of Morgagni | Child 7–12 years + less intense pain + bluish spot visible through the scrotal skin («blue dot» – pathognomonic) + undescended testicle | Normal testicular flow + hypoechoic avascular nodule at the apex |
| Strangulated inguinal hernia | Irreducible mass in the groin + nausea + vomiting + groin pain + child especially | Intestinal loop in the inguinal canal → surgical emergency |
| Ourlian orchid | Adolescent + adult + parotitis + fever + late orchitis (3-7 days after parotitis) | Increased flux (inflammatory orchitis) |
| Testicular cancer | Painless hard mass + young adult + may present with pain if torsion on tumor | Heterogeneous mass + abnormal vascularization → oncologic workup |
Diagnostic approach and surgical decision
- Fundamental 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)
- Spermatic cord detorsion rotate testicle in opposite direction to torsion → restore perfusion → rewarm + warm compresses × 10-15 minutes
- Bilateral orchiopexy 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 detorsion (emergency maneuver pending 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 and vomiting or if the testicle appears to have risen. Do not wait for the pain to pass. Do not consult a primary care clinic — go directly to the emergency department of a hospital with urological surgery services. Every minute counts: the testicle can be saved if surgery is performed within 6 hours. Clinique Omicron can perform the initial assessment and arrange for urgent transfer to the hospital if necessary. To make an appointment for post-surgical follow-up or a preventive consultation, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's Nurse Practitioners (NPs) recognize the clinical presentation of testicular torsion and immediately transfer to surgical emergency without unnecessary diagnostic delay, assess recurrent intermittent torsions (transient, spontaneously resolving scrotal pain), and refer to urology for elective prophylactic orchiopexy. They provide post-operative follow-up after orchiopexy or orchiectomy and educate adolescents and their families on warning signs requiring immediate urgent consultation. Consultations are available at several service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not substitute for the advice of an emergency physician or a urologist. Testicular torsion is an absolute surgical emergency — every minute of delay reduces the chances of saving the testicle. Never wait for the spontaneous disappearance of sudden acute testicular pain in an adolescent or young man — go to the emergency room immediately.
Omicron Clinic
Need to consult a doctor?
Treatment within 24-48 hours. In-clinic or telemedicine, anywhere in Quebec.
Insurance receipts. 7j/7. No family doctor required.