Testicular Torsion

Testicular torsion is a urological emergency caused by twisting of the spermatic cord, leading to venous congestion, reduced arterial blood flow, and eventual ischemic necrosis of the testicle. The salvage rate is ~90% within 6 hours, dropping to ~50% at 12 hours and ~10% at 24 hours.[1-2] It should be treated with the same urgency as acute stroke or STEMI.[3]

The following algorithm outlines the approach to evaluating scrotal masses, including the TWIST score risk stratification for torsion:

• Onset and character: Sudden, severe, unilateral scrotal/testicular pain — the hallmark symptom. Ask exact time of onset (critical for salvage window)[4-5]
• Associated symptoms: Nausea and vomiting are common and strongly predictive (present in majority of torsion cases)[6-7]
• Abdominal pain: Some patients (especially children) present with abdominal pain only — always ask about testicular pain in boys with abdominal pain[8]
• Prior episodes: Intermittent torsion-detorsion may present as recurrent episodes of self-resolving testicular pain[8]
• Activity/triggers: Antecedent trauma, physical activity, cold weather exposure[1]
• Timing: Symptom duration is the single most important prognostic factor — document precisely[2]
• Important negatives: Absence of dysuria, urethral discharge, fever (these suggest epididymitis instead)[1][9]

• Sudden onset of severe unilateral scrotal pain with nausea/vomiting
• High-riding testicle with transverse lie[1][6]
• Absent cremasteric reflex (OR 47.6 for torsion in one study)[1][7]
• Hard, swollen, exquisitely tender testicle[6][10]
• Symptom duration approaching or exceeding 6 hours — escalate immediately[2][5]
• Any boy with acute abdominal pain and scrotal findings[8]
• Bilateral scrotal pain (rare but catastrophic if bilateral torsion)

• ED pain management: IV/IM ketorolac, opioids (morphine, fentanyl) for analgesia; do not delay surgical consultation for pain control[4]
• Procedural sedation: Consider for manual detorsion if patient cannot tolerate the procedure due to pain[11]
• Spermatic cord block: Lidocaine injection at the external inguinal ring can facilitate manual detorsion[4]
• No role for antibiotics unless epididymitis is the confirmed diagnosis
• Contraindicated: Do not give antibiotics empirically and discharge if torsion has not been excluded

• NPO status: Keep patient NPO once torsion is suspected, as emergent surgical exploration is likely[5]
• No specific dietary triggers or long-term dietary considerations

• GU: Dysuria, urethral discharge, urinary frequency (suggests epididymitis/UTI rather than torsion)[9]
• GI: Nausea, vomiting, abdominal pain (common in torsion; abdominal pain may be the sole complaint in children)[8]
• Constitutional: Fever (more suggestive of infectious etiology — epididymo-orchitis)[9]
• MSK/Derm: Scrotal erythema, edema, warmth
• Heme: Prior history of bleeding disorders (relevant for surgical planning)

• Family history of torsion: A recognized risk factor; the bell-clapper deformity is often bilateral and may be familial[1]
• Prior urological history: Undescended testis, prior orchiopexy, inguinal hernia repair
• Collateral from parents/caregivers: Essential in pediatric patients — exact time of symptom onset, prior similar episodes, and whether the child has been reluctant to report genital pain[8]

• Bell-clapper deformity: The most important anatomical risk factor — excessive testicular mobility due to abnormal anchoring of the tunica vaginalis[1][4]
• Age: Bimodal distribution — peak incidence in neonates (first year of life) and adolescents aged 12–18 years[4-5]
• Family history of testicular torsion[1]
• Cold weather / hyperactive cremasteric reflex[1]
• Antecedent trauma[1][6]
• Prior episodes of intermittent testicular pain (intermittent torsion-detorsion)[8][12]
• Incidence: ~1 in 4,000 males younger than 25 years; 3.8 per 100,000 males <18 years annually[5-6]

• Torsion of the testicular appendage (appendix testis): Gradual onset of superior pole pain, blue dot sign pathognomonic but uncommon, cremasteric reflex preserved, treated conservatively[1][9]
• Epididymitis/epididymo-orchitis: More gradual onset, dysuria, urethral discharge, tender epididymis, positive Prehn sign, increased blood flow on Doppler; in sexually active males think Chlamydia/Gonorrhea, in prepubertal boys think enteric organisms[1][9]
• Incarcerated inguinal hernia: Inguinal swelling extending into scrotum, bowel sounds in scrotum, may have obstructive symptoms[13]
• Testicular trauma/rupture: History of direct trauma, scrotal hematoma
• Idiopathic scrotal edema: Bilateral scrotal wall edema without testicular tenderness, self-limited[13]
• Testicular tumor: Usually painless, firm mass; ~10% present with acute pain from hemorrhage into tumor
• Fournier's gangrene: Rapidly progressive scrotal erythema, crepitus, systemic toxicity — surgical emergency
• Henoch-Schönlein purpura: Scrotal involvement with characteristic purpuric rash

• Prior episodes of testicular pain (intermittent torsion-detorsion)[8]
• Previous orchiopexy or inguinal surgery
• Undescended testis (cryptorchidism)
• Known bell-clapper deformity
• Urogenital anomalies
• Bleeding disorders or anticoagulant use (surgical planning)

• Vital signs: Usually normal; tachycardia from pain; fever suggests infectious etiology
• Inspection: Scrotal erythema, edema, high-riding testicle, transverse lie[1][6]
• Palpation: Exquisitely tender, swollen, hard testicle[6][10]
• Cremasteric reflex: Stroke medial thigh → observe for ipsilateral testicular retraction. Absent reflex is the most sensitive physical finding (100% sensitivity in one series). However, its presence does not reliably exclude torsion[4][7]
• Prehn sign: Elevation of the scrotum — classically relieves pain in epididymitis but not torsion. Low reliability; should not be used to rule out torsion[11]
• Blue dot sign: Bluish discoloration at the superior pole — pathognomonic for torsion of the appendix testis but uncommonly seen[1]
• Inguinal exam: Assess for hernia, cord tenderness
• Abdominal exam: Rule out referred pain sources

• Labs are not required and should not delay surgical consultation or imaging[5]
• Urinalysis: May help differentiate from epididymitis (pyuria, bacteriuria suggest infection); typically normal in torsion
• CBC: Leukocytosis is nonspecific; may be mildly elevated in torsion from stress response
• STI testing: Urine NAAT for Chlamydia/Gonorrhea if epididymitis is suspected in sexually active patients
• Platelet-to-lymphocyte ratio (PLR): Emerging as a predictor of testicular necrosis in some studies, but not yet standard practice[14]

• First-line: High-resolution color Doppler ultrasonography — sensitivity ~95–100%, specificity ~94–98% for torsion[1][15]

Key US findings

• Decreased or absent intratesticular blood flow compared to contralateral side[13]
• Whirlpool sign of the spermatic cord — the most specific US sign, pathognomonic in adults[15-16]
• Enlarged, heterogeneous testis with associated hydrocele[13]
• Spermatic cord twisting (target-like concentric rings on cross-section)[13]
• Critical caveat: A normal ultrasound does not exclude torsion — preserved blood flow can occur with partial or early torsion. If clinical suspicion is high, proceed to surgical exploration regardless of US findings[4-5][17]
• Do not delay surgery for imaging when clinical suspicion is high (TWIST ≥5)[1][10]
• ACR Appropriateness Criteria (2024): Scrotal US with Doppler is the recommended initial imaging for acute scrotal pain without trauma[16]
• CT/MRI: Not indicated in the acute setting

• TWIST Score (Testicular Workup for Ischemia and Suspected Torsion):[6][10]
• Export Component Points References Testicular swelling 2[1-2]
• Hard testicle 2[1-2]
• Absent cremasteric reflex 1[1-2]
• Nausea/vomiting 1[1-2]
• High-riding testicle 1[1-2]
• Score 0–2 (Low risk): ~1–2% torsion rate → US may be sufficient to rule out[6][10]
• Score 3–4 (Intermediate risk): ~22% torsion rate → Obtain urgent Doppler US + urology consult[6]
• Score ≥5 (High risk): ~87% torsion rate → Proceed directly to surgical exploration; do not delay for imaging[6][10]
• The TWIST score has been validated when performed by non-urologists including EMTs, with NPV of 100% for low-risk and PPV of 93.5% for high-risk groups.[10] However, it should be used for risk stratification, not as an exclusionary tool, given a non-negligible false-negative rate.[18]
• POCUS by EPs: Sensitivity 96%, specificity 95% when assessing for impaired blood flow or whirlpool sign[18]
• Manual detorsion (see Treatment Plan): Can be performed as a bedside procedure, ideally with US guidance[11][19]

• Not routinely indicated for testicular torsion
• Consider ECG only if procedural sedation is planned for manual detorsion or if the patient has cardiac comorbidities

• Testicular torsion is a time-critical surgical emergency. Key assessment points:

Severity stratification by symptom duration

• 0–6 hours: ~97% salvage rate
• 7–12 hours: ~79% salvage rate
• 13–24 hours: ~42–54% salvage rate
• 24 hours: ~18% salvage rate (but still worth pursuing surgery)
• Atypical presentations to recognize: Isolated abdominal pain in children, intermittent torsion-detorsion with spontaneous resolution, neonatal torsion (painless scrotal mass with discoloration)[4][8]
• Complications: Testicular necrosis requiring orchiectomy (42% overall orchiectomy rate), testicular atrophy even after successful detorsion (significant risk beyond 6 hours), decreased fertility, contralateral testicular damage from immune-mediated mechanisms[5][20]
• Long-term follow-up shows testicular atrophy risk is higher than previously reported, with heterogeneous echotexture on US even in salvaged testes raising concerns about fertility impact[20]

Initial stabilization

• IV access, analgesia (ketorolac 0.5 mg/kg IV, opioids as needed), NPO status
• Immediate urology consultation — do not delay for imaging if clinical suspicion is high[4-5]

Manual detorsion in the ED

• Indicated as a temporizing measure while awaiting surgery — not definitive treatment[1][4][19]
• Classic technique: "Open the book" — rotate the affected testicle medially to laterally (toward the thigh). Most torsion occurs inward, so outward rotation detorses[11]
• Success indicators: Immediate pain relief, testicle descends to normal position, restoration of blood flow on Doppler[19][21]
• US-guided detorsion improves success rates and confirms reperfusion in real time[11][19]
• Success rate: ~26–80% depending on series; most effective when presentation delay is <6 hours and scrotal edema is absent[3][21-22]
• Successful manual detorsion was independently associated with improved surgical salvage (OR 17.38) and reduced orchiectomy from 24.6% to 2.8%[23]
• Manual detorsion is NOT definitive — all patients still require surgical orchiopexy[1][19]

Definitive surgical management

• Emergent scrotal exploration with surgical detorsion and bilateral orchiopexy (fixation of both testes to prevent future torsion)[1][5][8]
• If the testicle is nonviable → orchiectomy with contralateral orchiopexy[5]
• After successful manual detorsion, orchiopexy can be performed semi-electively (within 1–14 days) with no increased risk of re-torsion or orchiectomy[3][21]

Aggressive management even with prolonged symptoms

• Testicular survival is significant even past 24 hours — surgical exploration should be pursued regardless of symptom duration[2]

• Admission/OR: All confirmed or high-suspicion torsion cases require emergent surgical exploration[5]
• Transfer: If urology is not available on-site, arrange emergent transfer — inter-facility transfer significantly reduces salvage rates, so attempt manual detorsion before/during transfer[24]
• Observation: Not appropriate for suspected torsion. Intermediate-risk TWIST scores warrant urgent imaging and urology consultation, not observation alone[6]
• Discharge: Only if torsion has been definitively excluded (e.g., confirmed alternative diagnosis on US with low TWIST score). Ensure clear return precautions[4]
• Urology consultation triggers: Any concern for torsion — consult before imaging in high-risk cases[1]

• Post-orchiopexy follow-up: Urology follow-up within 1–2 weeks; long-term US monitoring for testicular atrophy recommended[20]
• Long-term surveillance: Testicular atrophy can develop months to years after salvage, even when initial surgery appeared successful — serial US monitoring of testicular volume is warranted[20]
• Fertility counseling: Discuss potential impact on fertility, especially with delayed presentation or orchiectomy; semen analysis may be considered in post-pubertal patients at appropriate follow-up[5][20]

Return precautions (counsel patient/family)

• Return immediately for any recurrence of sudden testicular pain, swelling, or nausea/vomiting
• Educate adolescents and parents that testicular pain is always an emergency and should never be ignored or "waited out"[8]
• Contralateral torsion can occur even after bilateral orchiopexy (rare)
• Expected recovery: Scrotal swelling and discomfort typically resolve over 1–2 weeks post-surgery

1. Scrotal Masses. — Langan RC, Puente MEE. American Family Physician. 2022.

2. A Systematic Review of Testicle Survival Time After a Torsion Event. — Mellick LB, Sinex JE, Gibson RW, Mears K. Pediatric Emergency Care. 2019.

3. The Role of Manual Detorsion in the Management of Testicular Torsion in the Emergency Department: A Single-Group Observational Study. — Başaran E, Baba D, Taşkiran AT, et al. Medicine. 2026.

4. High Risk and Low Prevalence Diseases: Testicular Torsion. — Lacy A, Smith A, Koyfman A, Long B. The American Journal of Emergency Medicine. 2023.

5. Testicular Torsion: Diagnosis, Evaluation, and Management. — Sharp VJ, Kieran K, Arlen AM. American Family Physician. 2013.

6. Clinical Diagnosis of Testicular Torsion. — Ebell MH. American Family Physician. 2022.

7. A Retrospective Review of Pediatric Patients With Epididymitis, Testicular Torsion, and Torsion of Testicular Appendages. — Kadish HA, Bolte RG. Pediatrics. 1998.

8. What Parents and Teens Need to Know About Testicular Pain. — Angulo MI, Collazo GR, Thompson LA. JAMA Pediatrics. 2025.

9. Differentiation of Epididymitis and Appendix Testis Torsion by Clinical and Ultrasound Signs in Children. — Boettcher M, Bergholz R, Krebs TF, et al. Urology. 2013.

10. Diagnosing Testicular Torsion Before Urological Consultation and Imaging: Validation of the TWIST Score. — Sheth KR, Keays M, Grimsby GM, et al. The Journal of Urology. 2016.

11. Successful Outcome of Manual Testicular Detorsion Using Point-of-Care Ultrasound Guidance: A Clinical Experience. — Hsu CT, Chiu PW. Pediatric Emergency Care. 2023.

12. Ultrasound Diagnostic Features and Management of Torsion-Detorsion. — Olawoyin O, Choksi AU, Press BH, et al. Urology. 2026.

13. Differential Diagnosis of Acute Scrotum in Childhood And Adolescence With High-Resolution Duplex Sonography. — Deeg KH. Ultraschall in Der Medizin. 2021.

14. Predictors of Testicular Salvage Failure in Pediatric Testicular Torsion: A Retrospective Analysis of Clinical and Imaging Risk Factors. — Tian Y, Xing X, Cai H, et al. Pediatric Surgery International. 2025.

15. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. — American College of Emergency Physicians (2023). 2023.

16. ACR Appropriateness Criteria® Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass: 2024 Update. — Expert Panel on Urological Imaging, Gerena M, Allen BC, et al. Journal of the American College of Radiology : JACR. 2024.

17. Detection of Testicular Torsion With Preserved Intratesticular Flow by Point of Care Ultrasound in the Emergency Department: A Case Report. — Lee DY, Lee SH, Yoon JA, et al. The Journal of Emergency Medicine. 2022.

18. Evaluating the TWIST Score and Point-of-Care Ultrasound for Paediatric Testicular Torsion. — Nakamura T, Kinoshita M, Ihara T, et al. Emergency Medicine Journal : EMJ. 2026.

19. Ultrasound-Guided Manual Testicular Detorsion in the Emergency Department. — Manivel V, Mirmiran B. The Journal of Emergency Medicine. 2020.

20. Testicular Atrophy Following Torsion in Pediatric Patients: Results of a Long-Term Follow-Up. — Milivojevic S, Topalovic D, Dasic I, et al. Urology. 2025.

21. Manual Detorsion in Testicular Torsion: 5 years of Experience at a Single Center. — Vasconcelos-Castro S, Flor-de-Lima B, Campos JM, Soares-Oliveira M. Journal of Pediatric Surgery. 2020.

22. The Role of Manual Detorsion in Pediatric Testicular Torsion During the Global COVID-19 Pandemic: Experience From 2 Centres. — Russo T, Cozzi DA, Gaglione G, Ceccanti S. Urology. 2023.

23. Improving Organ Salvage in Testicular Torsion: Comparative Study of Patients Undergoing vs Not Undergoing Preoperative Manual Detorsion. — Dias Filho AC, Oliveira Rodrigues R, Riccetto CL, Oliveira PG. The Journal of Urology. 2017.

24. Multicenter Retrospective Analysis of Acute Scrotum in the Kyushu-Okinawa Region: Diagnostic Practices, Management Patterns, and Predictors of Testicular Salvage. — Tobu S, Kakinoki Y, Konomoto T, et al. International Journal of Urology : Official Journal of the Japanese Urological Association. 2025.