Intermittent Testicular Torsion

Intermittent testicular torsion is recurrent twisting of the spermatic cord that untwists on its own, causing sudden severe testicular pain that settles within minutes to a few hours. Between episodes the testis is normal. It is also called torsion detorsion.

It affects mainly adolescents and young men, with a peak at 12 to 18 years. The risk is progression to complete torsion, which is a surgical emergency.

Pathophysiology. The usual substrate is the bell clapper deformity, in which the tunica vaginalis attaches high on the cord, so the testis lies horizontally and rotates freely. The deformity is bilateral in about 40% or more of affected men.

Each episode causes ischaemia followed by reperfusion. Repeated episodes can injure germ cells and lead to atrophy, and raise the chance that a later twist will not untwist.

Salvage after complete torsion depends on time: about 90 to 100% within 6 hours, about 50% by 12 hours, and under 10 to 20% after 24 hours.

Recurrent sudden unilateral scrotal, groin or lower abdominal pain, with nausea and vomiting, often at night, after exertion or after cold exposure. Pain settles spontaneously, and may recur over weeks to months. Between episodes, examination is normal. During an episode the testis is high, horizontal, tender and swollen, with an absent cremasteric reflex.

Pain that does not settle within 1 hour is treated as complete torsion until proven otherwise, and the patient goes straight to theatre.

• The history is the main basis for the diagnosis, and imaging does not exclude it.
• During an episode with doubt, calculate the TWIST score: testicular swelling 2, hard testis 2, absent cremasteric reflex 1, nausea or vomiting 1, high riding testis 1. A score of 5 or more is high risk and goes directly to exploration, 3 to 4 is intermediate and needs Doppler ultrasound, and 0 to 2 is low risk.
• Doppler ultrasound: reduced or absent flow, a twisted cord (whirlpool sign) and a horizontal lie during an episode. Normal flow between episodes, or even during one, does not exclude torsion. Never delay exploration for imaging when the suspicion is strong.
• Urinalysis to exclude infection. Ultrasound of the opposite side to document the lie.

Differential diagnosis.

• Epididymo orchitis
• Torsion of the appendix testis
• Inguinal hernia
• Testicular tumour
• Renal colic with referred pain
• Idiopathic scrotal oedema
• Henoch-Schonlein purpura
• Trauma

• Pain that persists or recurs soon after relief: emergency scrotal exploration.
• Analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g daily), ibuprofen 400 mg orally every 8 hours with food, and morphine 2 to 5 mg intravenously, titrated, for severe pain. Keep the patient fasted.
• Manual detorsion may be attempted while arranging theatre, using the open book technique: rotate the testis outward (the right testis anticlockwise and the left clockwise, viewed from the feet) by 180 degrees, repeating until pain relief and a normal lie, up to 2 full turns. Pain relief confirms success. Surgery is still needed afterwards, and detorsion must not delay it.
• Definitive treatment for confirmed episodes, even if history alone is the basis: scrotal exploration with bilateral orchidopexy. Fix the testis at 3 points to the tunica dartos, with non-absorbable 3/0 or 4/0 suture (polypropylene), and fix the other testis in the same operation. Schedule it within days to weeks of the last episode, sooner if episodes are frequent.
• Non-viable testis at exploration (black, with no return of colour after detorsion and warm saline for 10 to 15 minutes): orchidectomy, with fixation of the other testis.
• Perioperative cefazolin 2 g intravenously (3 g if over 120 kg) as a single dose, where an implant or prolonged surgery is expected.
• Complications: haematoma, infection, recurrence (rare after correct fixation), atrophy and chronic pain.
• Counselling: any new pain lasting over 1 hour is an emergency, with no waiting at home.

Monitoring. Wound review at 2 weeks, and at 6 weeks. Ultrasound of testis size at 3 months after prolonged episodes. Semen analysis in adults with atrophy.

Referral and escalation. Refer to urology urgently for any suspected case. Immediate theatre for persistent pain, a high riding testis, or an intermediate or high TWIST score.