Intravaginal testicular torsion brings about a sudden onset of sever unilateral scrotal pain which is often followed by inguinal and/or scrotal swelling [7]. Gradual onset of pain is an uncommon presentation. Torsion may happen following physical activity or sports. It can also be related to trauma in around 4 to 8% of cases. It can also develop spontaneously.

Generally, one third of patients present with gastrointestinal upset followed by nausea and vomiting. In the pediatric group, nausea and vomiting often leads to a positive diagnosis 96% of the time.

• Crying

  All children were admitted because of the inconsolable cry, abdominal pain, and the swelling of the groin. Three patients underwent orchidectomy, while the other 3 patients underwent detorsion and cryptorchidopexy. [ncbi.nlm.nih.gov]

  Discuss with Paediatric surgeon Incarcerated hernia Intermittent inguinoscrotal swelling, associated irritability +++Pain Worse with crying Nausea and Vomiting – if bowel entrapment Firm, tender, irreducible inguinoscrotal swelling Requires reduction [rch.org.au]

• Abdominal Pain

  RESULTS: The most common presenting symptoms were abdominal pain and vomiting. [ncbi.nlm.nih.gov]

  Other studies report an 11% to 12.5% incidence of abdominal pain as the sole presenting feature of testicular torsion. 4-6 Presentation with abdominal pain is related to the abdominal location of the testes in the embryonic period, and the fact that the [consultant360.com]

• Scrotal Pain

  The present study assessed parental knowledge regarding acute scrotal pain. [ncbi.nlm.nih.gov]

  Algorithmic approach to the evaluation of the patient with acute scrotal pain. Evaluation of Acute Scrotal Pain Figure 2. Algorithmic approach to the evaluation of the patient with acute scrotal pain. [aafp.org]

  Patients and methods: Six patients who presented clinically with acute scrotal pain and had spermatic cord torsion, proven at surgery. All patients were initially studied with color Doppler US, and intratesticular flow was detected in all of them. [doi.org]

• Testicular Pain

  Advanced practice nurses should consider the differential diagnosis of testicular torsion for any patient with testicular pain despite the patient's age, history, or physical examination findings. [ncbi.nlm.nih.gov]

  Testicular torsion usually presents with severe testicular pain or pain in the groin and lower abdomen. Pain generally begins suddenly and typically involves only one side. There is often associated nausea and vomiting. [en.wikipedia.org]

  The inclusion criterion was intermittent testicular pain over a 3-month duration, and the degree of testicular pain was evaluated by visual analog pain score. The positions and activities that might have triggered the pain were noted. [karger.com]

  Patients may also have abdominal pain. There may be a history of previous testicular pain. Fever may also accompany the testicular pain. [emedicinehealth.com]

• Swelling of the Scrotum

  Take your child to the emergency department immediately if he experiences any of the following symptoms: Scrotal pain that develops suddenly Increasing scrotal pain despite treatment with pain medication Redness and swelling of the scrotum Scrotal pain [chop.edu]

  Did you observe any swelling around your newborn’s scrotum recently? Does your adolescent son complain of severe pain in the scrotum, and does he also suffer from nausea and vomiting? Chances are, that he may be suffering from testicular torsion. [momjunction.com]

  Men with testicular torsion will likely experience acute, intense pain and swelling in the scrotum. [denverurology.com]

  Boys with testicular torsion get sudden pain and swelling of the scrotum. The affected testicle usually becomes reddened and very painful. The condition may be so painful that it causes nausea and vomiting. [netdoctor.co.uk]

• Scrotal Mass

  To salvage the testis, most urological surgeons advocate early exploration of enlarging scrotal masses or suspected testicular ruptures resulting from trauma. [ncbi.nlm.nih.gov]

  Prenatal torsion manifests as a firm, hard, scrotal mass, and is usually asymptomatic. The scrotal skin characteristically fixes to the necrotic gonad. [sonoworld.com]

• Testicular Disease

  Several studies have demonstrated its potential in the differentiation between diseased and normal tissue in clinical practices, however the applicability to testicular disease has not been well elucidated. [ncbi.nlm.nih.gov]

  Ultrasonography also can differentiate testicular disease (e.g., torsion, tumor) from extratesticular disease (e.g., hydrocele, abscess, hematoma). [aafp.org]

  […] primarily a disease of adolescents and neonates. [emedicine.com]

Diagnosis for this condition is often made based on the history of the individual and the signs and symptoms they present [8]. In cases where the history and physical examinations are convincing enough, instant surgery can commence. A Doppler ultrasound can be used when diagnosis is not clear. Diagnostic procedures must however, not delay treatment. The cost of surgery following unsure diagnosis is far lower than the cost of testicular loss as a result of delayed treatment following lengthy diagnostic procedures.

Surgical treatment helps prevent additional ischemic damage to the testis. Observation, instead of treatment may be appropriate in some cases however, depending on pathology. [symptoma.com]

Surgical exploration provides definitive treatment for the affected testis by orchiopexy and allows for prophylactic orchiopexy of the contralateral testis. Surgical treatment of torsion of the appendix testis is not mandatory but hastens recovery. [ncbi.nlm.nih.gov]

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Successful management of spermatic cord torsion is measured by immediate testicular salvage as well as the incidence of late testicular atrophy [6]. The length of time between onset of symptoms and detorsion (treatment) and the corresponding rate of successful testicular salvage is as follows:

• Less than 6 hours: 90 to 100% salvage rate
• 12 to 24 hours: 20 to 50% salvage rate
• Higher than 24 hours: 0 to 10% salvage rate

The complications of testicular torsion include:

• Infarction of testicle
• Infection
• Loss of testicle
• Infertility as a result of testicular loss
• Cosmetic deformity 

In neonates or fetus, extravaginal torsion often occurs because the testes may freely rotate before the development of testicular fixation through the tunica vaginalis within the scrotum [3].

With normal testicular suspension comes firm fixation of the epididymal-testicular complex posteriorly and this generally prevents the spermatic cords from twisting. In males with the bell-clapper condition, torsion often occurs as a result of a lack of fixation and this leads to the testes becoming freely suspended within the tunica vaginalis.

An abnormal mesentery between the testes as well as its blood supply can predispose it to torsion as long as the testicle is broader than the mesentery. Contraction of the spermatic muscles usually shortens the spermatic cords and can also lead to testicular torsion.

Extarvaginal torsion is the cause of 5% of all torsion cases [4]. Out of these 5% of cases, 70% will occur prenatally and the other 30% will occur postnatally. Extravaginal torsion is often linked with high birth weight. Bilateral perinatal torsion is believed to be rare but there has been an increase in reported number of cases, with 56 cases currently documented in diverse literature.

Intravaginal torsion is the cause of 16% of cases. This type of testicular torsion is mostly seen in males who are younger than 30 years of age with majority of cases affecting people aged 12 to 18 years. The peak of incidence is placed at 13 to 14 years. The left testis is often most affected with bilateral cases only accounting for 2% of all torsions.

The incidence of torsion in males that are younger than 25 is approximately 1 in 4000.

Familial testicular tension has been described as 11.4% of cases have a positive family history.

The testicle is able to rotate freely in the spermatic cord within the tunica vaginalis amongst males who have a very high attachment of the tunica vaginalis as well as abnormal fixation to the muscles and fascial coverings of the spermatic cord [5]. This anomaly is congenital and is referred to as the bell-clapper deformity. It often results in the long axis of the testicle showing transverse orientation instead of showing cephalocaudal orientation.

This congenital abnormality is seen in 12% of males and is bilateral in around 40% of cases. The bell-clapper deformity makes it possible for the testicle to twist spontaneously on the spermatic cord. Torsion is seen when the testicle rotates between 90° and 180°. This normally compromises blood flow to and from the testicle. When the testicle twists 360° or more, complete torsion is said to have occurred. Incomplete or partial torsion often occurs with lesser degrees of rotation. In some cases, degree of torsion may extend to as much as 720°.

With the twisting of the testicle comes venous occlusion and engorgement and also arterial ischemia and testicular infarction.

The bell-clapper syndrome is a trait seen in some males. Since this is the major risk factor in testicular torsion, it is important for such people to undergo surgery so as to have both testicles attached properly to the inside of the scrotum [10].

Testicular torsion is defined as the torsion of the spermatic cord structures. When this happens there is a loss of blood supply to the ipsilateral testicle [1]. The condition is treated as an emergency because the preservation of the testicle and ultimately fertility is dependent on early diagnosis and treatment.

Testicular torsion is a disease that primarily affects adolescents and neonates and it is the main cause of testicular loss within this age.

Surgical treatment helps prevent additional ischemic damage to the testis. Observation, instead of treatment may be appropriate in some cases however, depending on pathology [2]. Diagnosis of testicular torsion is clinically and it is very important for diagnostic procedures to not get in the way of early treatment.

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2. Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63.
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4. Kar A, Ozden E, Yakupoglu YK, Kefeli M, Sarikaya S, Yilmaz AF. Experimental unilateral spermatic cord torsion: the effect of polypolymerase enzyme inhibitor on histopathological and biochemical changes in the early and late periods in the ipsilateral and contralateral testicles. Urology. Aug 2010;76(2):507.e1-5.
5. Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. Sep 2010;28(7):786-9.
6. Das S, Singer A. Controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations. J Urol 1990; 143:231.
7. Gillenwater JY, Burros HM. Torsion of the spermatic cord in utero. JAMA 1966; 198:1123.
8. McFarland JB. Testicular strangulation in children. Br J Surg 1966; 53:110.
9. Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int 2003; 92:200.
10. Kaye JD, Levitt SB, Friedman SC, et al. Neonatal torsion: a 14-year experience and proposed algorithm for management. J Urol 2008; 179:2377.