Testicular torsion is treated with emergency surgery to untwist the spermatic cord and restore blood flow to the testicle. In some cases, a doctor may first attempt to untwist the testicle by hand, but surgery is almost always needed afterward to permanently fix the testicle in place and prevent it from twisting again. The single most important factor in treatment is speed: when blood flow is restored within six hours, the testicle survives about 97% of the time.
Why Time Is Critical
Each testicle gets its entire blood supply through the spermatic cord. When the cord twists, that blood supply is completely cut off. Without it, the testicle begins to suffer damage and will eventually die. A systematic review of over 1,200 patients found clear survival rates at each time window:
- 0 to 6 hours: 97.2% survival
- 7 to 12 hours: 79.3% survival
- 13 to 24 hours: 54.0% survival
- Beyond 24 hours: 18.1% survival
After roughly six hours without blood flow, the testicle begins to shrink permanently. Beyond that window, the chance of saving it drops sharply with every passing hour. This is why testicular torsion is treated as one of the few true urological emergencies.
Manual Detorsion: The First Step
If a doctor suspects torsion, they may try to untwist the testicle by hand before surgery. This is sometimes called the “open book” maneuver because the rotation mimics opening the spine of a book. For the left testicle, the doctor rotates it clockwise; for the right, counterclockwise. Each rotation covers 180 degrees, and the maneuver may need to be repeated two or three times, since torsion can involve anywhere from a half-turn to two full turns of the cord.
Success is usually obvious right away: the patient feels immediate pain relief. Manual detorsion works in roughly 30 to 70% of cases. Even when it succeeds, surgery is still needed afterward to stitch the testicle in place so it can’t twist again.
How Diagnosis Works
Doctors often diagnose torsion based on a physical exam alone, especially when the symptoms are classic: sudden, severe pain on one side of the scrotum, swelling, and sometimes nausea or vomiting. When the diagnosis is uncertain, a color Doppler ultrasound can check whether blood is flowing to the testicle. Combined data across studies show this imaging technique has about 92% sensitivity and 99% specificity, making it highly reliable. However, if torsion is strongly suspected, most surgeons will proceed directly to surgery rather than wait for imaging, since every minute counts.
Surgery: Orchiopexy
The definitive treatment is a procedure called orchiopexy. Here’s what happens during the operation:
- The surgeon makes a small incision in the scrotum.
- They untwist the spermatic cord and examine the testicle.
- If the testicle looks healthy and has good color once blood flow returns, the surgeon stitches it directly to the inside wall of the scrotum. This prevents it from twisting again.
- If the testicle appears dead or severely damaged, it is removed. In that case, a prosthetic (artificial) testicle can be placed later.
- The incision is closed with dissolvable stitches.
Surgeons almost always fix the opposite testicle during the same operation. The anatomical trait that allows torsion, sometimes called a “bell clapper” deformity where the testicle hangs freely inside the scrotum rather than being anchored, typically affects both sides. Fixing only one would leave the other at risk.
Recovery After Surgery
Recovery from orchiopexy is relatively straightforward. Most people return to work within about a week, though physical jobs may require a bit longer. You should avoid vigorous exercise and sports for four to six weeks. Sexual activity can typically resume after about two weeks, or whenever it feels comfortable. The stitches dissolve on their own and don’t need to be removed.
Recurrence after surgical fixation is rare. A large review spanning a decade of cases found a recurrence rate of just 1.3% after orchiopexy.
Long-Term Effects on Fertility and Hormones
One of the biggest concerns after torsion is whether it affects the ability to have children. The picture is somewhat reassuring, though not entirely straightforward.
Hormone levels, including testosterone, generally remain normal after torsion. Most studies find that the testicles continue to produce hormones at expected levels, even when one testicle is lost. So torsion typically does not cause low testosterone or related symptoms.
Sperm quality is a different story. Torsion has been shown to reduce sperm counts and sperm motility (how well sperm swim) over the long term. This appears to result from the initial period without blood flow, plus additional damage that occurs when blood flow returns, a process called reperfusion injury. These effects can show up on semen analysis even when the testicle is successfully saved.
Despite these changes in sperm parameters, the one study that directly tracked pregnancy rates found no decrease in paternity among men who had been treated for torsion compared to the general population. In practical terms, most men who experience torsion go on to father children, though some may face a longer path to conception or benefit from a fertility evaluation if they’re having difficulty.