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.

• Pain

  The patient typically develops acute onset severe unilateral testicular pain. The pain may also radiate to the lower abdominal with nausea and vomiting. [emed.ie]

  16, 29, 30 The pain usually resolves spontaneously within a few hours. [aafp.org]

  The change in the approach to clinical problem of undiagnosed scrotal pain requires joint effort on the part of urologists and radiologists. [omicsonline.org]

  Of the total number of operated patients, 9 presented with abdominal pain but without initial scrotal pain, and only they were included in the study. [ncbi.nlm.nih.gov]

• Swelling

  In neonates, extravaginal torsion predominates, with the entire cord, including the processus vaginalis, twisting. 10 Extravaginal torsion may occur antenatally or in the early postnatal period and typically presents as painless scrotal swelling, with [aafp.org]

  Swelling within one side of the scrotum ( scrotal swelling ). Nausea or vomiting. [nlm.nih.gov]

  Physical examination showed a pronounced swelling of the left hemiscrotum which was inflamed and seemed tender. The swelling had been present for almost 48 h but gradually had become worse. [doi.org]

  With epididymitis, pain and swelling are usually less acute and initially localized to the epididymis. However, in both conditions, generalized swelling and tenderness often develop, making it difficult to distinguish torsion from epididymitis. [merckmanuals.com]

  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]

• Severe Pain

  Severe pain develops suddenly in the testis. Swelling soon follows. The pain may seem to come from the abdomen, and nausea and vomiting may develop. Sometimes fever develops. Affected people may need to urinate frequently. [msdmanuals.com]

  Surgery can save the testicle, but it needs to be performed within 6-8 hours after the pain started What are the symptoms? Severe pain in the testicle that can even wake a boy from sleep. The pain does not get better, it gradually gets worse. [cheo.on.ca]

  Causes of testicular torsion Severe pain the groin is a sign of a twisted testicle. Each testicle is attached to the spermatic cord and the scrotum. [medicalnewstoday.com]

• Infertility

  CONCLUSIONS: Local injection of allogenic MSCs before surgical detorsion is a simple, clinical friendly procedure to rescue torsion-induced infertility. [ncbi.nlm.nih.gov]

  Best practice policies for male infertility. The Journal of Urology 2002 ;167 (5): 2138 – 44. Google Scholar | Medline [2] Irvine, DS. Epidemiology and aetiology of male infertility. Human Reproduction 1998 ;13 (April ( Suppl. 1 )): 33 – 44. [doi.org]

• Inguinal Hernia

  We successfully salvaged the testicle in addition to performing inguinal hernia reduction and repair. [ncbi.nlm.nih.gov]

  There were no signs of inguinal hernia or fever. A flashlight test revealed transillumination of a right hydrocele and opacity of the left scrotum. [nejm.org]

  The most common conditions in the differential diagnosis include epididymitis, strangulated inguinal hernia, traumatic hematoma, testicular tumor, or testicular fracture. [doi.org]

• 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]

• Constipation

  He reported having mild constipation with bowel motions every 2 to 3 days, occasional straining, and hard stools but no blood. Physical examination. The patient looked uncomfortable but nontoxic. He was afebrile, with stable vital signs. [consultant360.com]

  Hernia LEFT: herniated bowel in preterm.RIGHT: left-sided hernia in constipated child due to intermitted herniation of sigmoid. Hernias in children are common especially in premature infants. [radiologyassistant.nl]

• Severe Abdominal Pain

  Second, his severe abdominal pain interfered with the detection of mild testicular tenderness at presentation; only after his abdominal pain had improved was it possible to confirm the presence of scrotal tenderness. [consultant360.com]

• Abdominal Mass

  Examination revealed a left testicular mass at birth which was hard, elevated, slightly enlarged and not trans-illuminant. Abdominal masses were not detected, and the right testicle was descended and normal. [jcnonweb.com]

• Suggestibility

  If history and physical examination suggest testicular torsion, immediate surgical consultation and exploration should take precedence over diagnostic tests. Usually affects young males but may affect males of any age. [bestpractice.bmj.com]

  Some have suggested that surgical exploration is unnecessary [8]. Some reports suggest that the contralateral testicle is not at increased risk for torsion. They feel that there is no evidence that a contralateral orchidopexy is protective [7-10]. [jpss.eu]

  Emergency technetium Tc 99m pertechnetate scintigraphy showed hypoperfusion in both sides suggesting testicular torsion. The patient underwent surgery immediately. [ncbi.nlm.nih.gov]

  C 25, 38 – 40 Immediate surgery should be performed if testicular torsion is suspected, and should not be delayed by imaging studies if physical examination findings are strongly suggestive. [aafp.org]

• Stroke

  The cremasteric reflex (L1/L2 spinal nerves) - gentle pinching or stroking of the inner thigh while observing the scrotal contents. [emed.ie]

  […] in postpubertal boys: 65% occur in boys ages 10-20 years old Asymmetric high riding testicle “bell clapper deformity” Negative prehn's sign (lifting of testicle will not relieve pain) Loss of cremasteric relex (elevation of the testes in response to stroking [smartypance.com]

  Features on examination: Absence of cremasteric reflex The cremasteric reflex is illicited by stroking/pinching the medial aspect of the thigh, causing a contraction of the cremasteric muscle, and elevation of the ipsilateral testicle at least 0.5cm. [aci.health.nsw.gov.au]

  The cremaster reflex is elicited by lightly stroking the skin of the inner thigh causing the cremaster muscle to contract and elevate the testicle. The odds ratio for absence of a cremaster reflex has been reported from 4.8-27.8. [emdocs.net]

• Forgetful

  Do not forget to include testicular torsion in differential diagnosis of lower acute abdominal pain in young males. J Pediatr Urol. 2013;9(6 pt B):1161-1165. Williamson RCN. Torsion of the testis and alied conditions. Br J Surg. 1976;63:465-476. [consultant360.com]

  Pogorelić Z, Mrklić I, Jurić I: Do not forget to include testicular torsion in differential diagnosis of lower acute abdominal pain in young males. J Pediatr Urol 2013;9:1161-1165. [karger.com]

• Irritability

  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]

• Decreased Cremasteric Reflex

  The cremasteric reflex in epididymitis is usually present. Testicular torsion, or more probably impending testicular infarction, can also produce a low-grade fever. There is often an absent or decreased cremasteric reflex. [en.wikipedia.org]

• Scrotal Pain

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

  Algorithm for evaluating acute scrotal pain. Information from reference 9. Evaluation of the Acute Scrotum Figure 2. Algorithm for evaluating acute scrotal pain. Information from reference 9. [aafp.org]

  Introduction Acute scrotal pain with or without swelling and erythema in the child or adolescent male should be treated as an emergent condition. [pedsinreview.aappublications.org]

  Complication Patients Scrotal hematoma 2 Epididymorchitis/scrotal abscess 2 Chronic testicular pain 1 Pulmonary oedema 2 Table 1: Complications of scrotal exploration. [omicsonline.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]

  Furthermore, whilst CDUS was useful in confirming/ruling out testicular torsion, its utility in diagnosis of other causes of acute testicular pain in our series was limited. [omicsonline.org]

  The patient typically develops acute onset severe unilateral testicular pain. The pain may also radiate to the lower abdominal with nausea and vomiting. [emed.ie]

  It manifests with acute testicular pain. [icd9data.com]

  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]

• 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]

  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]

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

• 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.

Because the time to treatment was reported variously in different case series, the 3 most common formats for reporting time to treatment and outcome were used. When overlap between the tables existed, the data were tallied and reported cumulatively. [ncbi.nlm.nih.gov]

Most of the conditions are nonemergent, but the prompt diagnosis and treatment of torsion of the spermatic cord is imperative to avoid permanent ischemic damage to the testicle. [pedsinreview.aappublications.org]

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.

1. Schneck FX, Bellinger ME. Abnormalities of the testis and scrotum and their surgical management. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell- Walsh Urology. 9th ed. Philadelphia, Pa: WB Saunders; 2007:Chapter 127.
2. Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63.
3. Roth CC, Mingin GC, Ortenberg J. Salvage of bilateral asynchronous perinatal testicular torsion. J Urol. Jun 2011;185(6 Suppl):2464-8.
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.