Testicular Torsion is a medical condition caused by the twisting of blood vessels to the male gonad. This occurs when the spermatic cord, which houses the blood vessels, nerves, and the tube that carries sperm, rotates on itself. The resulting twist cuts off the blood supply to the testicle, causing ischemia and rapid tissue damage. Because the testicle’s survival depends entirely on this blood flow, Testicular Torsion is a surgical emergency requiring immediate attention.
How Testicular Torsion Occurs
Torsion begins with a structural abnormality that allows the testicle to move and rotate freely within the scrotum. Normally, the testicle is securely anchored to the back wall of the scrotum, which prevents such movement. However, some individuals are born with a congenital defect where the protective outer layer, the tunica vaginalis, surrounds the testicle and spermatic cord higher up than usual.
This anatomical variation is often referred to as the “bell clapper” deformity, meaning the testicle hangs freely, making it susceptible to spontaneous twisting. When the rotation occurs, the spermatic cord structures—including the testicular artery and vein—become tightly constricted. The thin-walled veins are usually compressed first, leading to congestion and swelling. Eventually, the thicker-walled artery is blocked, which completely halts oxygen delivery.
Identifying Symptoms and the Time Criticality
The most common sign of Testicular Torsion is the sudden onset of intense pain in one testicle. This pain often wakes the individual from sleep and can radiate up into the groin or the lower abdomen. The affected side of the scrotum typically becomes swollen, tender, and may appear red or darkened due to the lack of blood flow.
The pain often triggers associated symptoms such as nausea and vomiting in a significant number of patients. Additionally, the affected testicle may appear to be riding higher in the scrotum than the unaffected one, or it may lie in an unusual horizontal position. This sudden presentation demands immediate medical evaluation, as the viability of the testicle depends heavily on the time elapsed.
The time from the onset of pain to the restoration of blood flow is the most important factor in determining the outcome. Irreversible damage to the testicular tissue, known as necrosis, begins rapidly. If the torsion is corrected within four to six hours, the chances of saving the testicle are high, often exceeding 90%. After about 12 hours, the salvage rate drops significantly to approximately 50%, and after 24 hours, the chance of saving the testicle is low.
Clinical Diagnosis and Emergency Management
Upon arrival at the emergency department, a physician performs a physical examination to look for the characteristic signs of torsion. A suggestive finding is the absence of the cremasteric reflex on the affected side. This is the normal reflex where the testicle pulls upward when the inner thigh is lightly stroked. The examination may also confirm the high-riding or transverse lie of the testicle.
To confirm the diagnosis and rule out other causes of scrotal pain, a Doppler ultrasound is usually performed to visualize blood flow to the testicle. The ultrasound measures blood flow velocity, and an absence or significant reduction of flow is a strong indicator of torsion. If the physical exam is highly suspicious, emergency surgery may proceed without waiting for imaging, as time is the limiting factor.
If surgery is not immediately available, a doctor may attempt manual detorsion, which involves carefully rotating the testicle by hand to untwist the spermatic cord. This maneuver can provide immediate pain relief and temporarily restore blood flow, though it is not a definitive treatment. Even if manual detorsion is successful, it must be followed immediately by surgery to prevent the cord from twisting again.
Definitive Surgical Treatment and Prognosis
Definitive treatment requires an urgent surgical procedure called scrotal exploration. The surgeon makes a small incision in the scrotum to access the spermatic cord and physically untwist the testicle to restore its blood supply. Once untwisted, the testicle is monitored for viability. If the tissue remains healthy, the surgeon performs an orchiopexy, which involves stitching the testicle to the inner scrotal wall.
This anchoring procedure is performed on the affected testicle and routinely on the unaffected testicle. This is because the underlying anatomical predisposition, the bell clapper deformity, is often present bilaterally. Securing both testicles prevents a recurrence of torsion in the future. If the affected testicle is deemed non-viable after untwisting due to prolonged ischemia, it must be surgically removed, a procedure known as an orchiectomy.
The patient’s long-term prognosis is directly tied to the duration of the torsion before surgical intervention. Successful salvage, especially within the first few hours, reduces the risk of long-term complications like testicular atrophy or fertility issues. While the remaining healthy testicle is often enough to maintain normal hormone production and fertility, prompt treatment offers the best chance for the preservation of both organs.