Twisted Up: Testicular Torsion, Part 1

Testicular torsion is a time-critical cause of acute scrotal pain and sometimes isolated abdominal pain. No single history or exam finding rules it out, including the cremasteric reflex, and salvage falls sharply as detorsion is delayed.

Recognizing and Risk-Stratifying Torsion

• Time-sensitive ischemic process: Torsion begins as venous outflow obstruction and progresses to arterial ischemia, with severe injury starting around 4 to 6 hours after symptom onset.
• Typical and atypical presentation: Sudden unilateral testicular pain is classic, but about 20% present with abdominal or flank pain alone, making missed torsion an easy diagnostic trap.
• High-yield exam findings: A tender, swollen, firm, high-riding testicle with a horizontal lie strongly raises concern, while scrotal erythema and hydrocele are later findings.
• Cremasteric reflex limitation: An absent reflex supports torsion, but its presence does not exclude it; roughly 40% of torsion cases can still have a cremasteric reflex. That pitfall is worth hearing in the episode.
• TWIST score utility: The TWIST score packages swelling, hard testis, nausea or vomiting, absent cremasteric reflex, and high-riding testis into a bedside risk tool that can guide who needs ultrasound versus immediate urology involvement.

Imaging and Emergency Management

• Doppler ultrasound first line: Ultrasound with Doppler is the preferred initial test, looking for absent or decreased intratesticular flow, with reported sensitivity and specificity both commonly above 85%.
• Named ultrasound red flags: The whirlpool sign points to a twisted spermatic cord, and a pseudomass can reflect congested epididymal and cord structures beneath the torsion point.
• Normal scan caveat: A reassuring ultrasound does not fully clear a concerning story, especially with intermittent or incomplete torsion, so urology still needs to hear about high-suspicion cases.
• Definitive surgical treatment: Surgical exploration with detorsion and fixation is the standard of care, and the opposite testicle is usually fixed as well because bell-clapper anatomy is often bilateral.
• Manual detorsion role: When confirmed torsion faces a major delay to the OR, manual detorsion can be a salvage move with reported success around 30% to 70%. We get into the bedside technique in the episode.
• Outcome curve urgency: Best outcomes occur when detorsion happens within 6 hours, with survival dropping from about 97% early to single digits beyond 48 hours.

References:

1. Rosenberg H, Long B, Keays M. Just the facts: assessment and management of testicular torsion in the emergency department. CJEM. 2021 Nov;23(6):740-743. doi: 10.1007/s43678-021-00189-6. Epub 2021 Aug 18. PMID: 34406643.
2. Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. PMID: 28953100.
3. Barbosa JA, Tisea BC, Barayan GA, Rosman BM, Torricelli FCM, Passerotti CC, Srougi M, Retik AB, Hguyen HT. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859–64. PMID: 2310800
4. Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol. 2016;195(6):1870-1876.  PMID: 26835833
5. Qin KR, Qu LG. Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score. J Urol. 2022;208(1):62-70. PMID: 35238603 
6. Gold DD, Lorber A, Levine H, et al. Door To Detorsion Time Determines Testicular Survival. Urology. 2019;133:211-215.  PMID: 31408640