Testicular Torsion

Testicular torsion is twisting of the spermatic cord causing obstruction of testicular venous drainage followed by arterial ischaemia.

It is a time critical surgical emergency.

The common adolescent form is intravaginal torsion caused by a bell clapper deformity, where the testis lacks normal posterior fixation and can rotate freely within the tunica vaginalis.

Testicular viability declines rapidly with duration of torsion.

Best salvage rates occur when detorsion occurs within approximately 4 to 6 hours.

After 12 hours, salvage falls substantially.

After 24 hours, irreversible infarction is common.

Typical presentation:

• Sudden severe unilateral scrotal pain
• Nausea or vomiting
• High riding testis
• Horizontal lie
• Scrotal swelling
• Absent ipsilateral cremasteric reflex

Pain may radiate to the lower abdomen.

A child with unexplained lower abdominal pain should have the testes examined.

Previous self resolving attacks suggest intermittent torsion.

Do not be reassured by:

• Absence of vomiting
• Presence of some cremasteric activity
• Partial pain improvement

when the overall presentation remains concerning.

Diagnosis is clinical when suspicion is high.

Do not delay exploration for ultrasound when the history and examination strongly indicate torsion.

Colour Doppler ultrasound is useful when diagnosis is genuinely uncertain and imaging is immediately available.

Reduced or absent intratesticular perfusion supports torsion.

Early or intermittent torsion can still show preserved arterial flow.

Immediate surgery

Perform urgent scrotal exploration.

Do not delay for fasting time, routine laboratory testing or transfer for sophisticated imaging when surgery is available.

Manual detorsion

Can be attempted while theatre is being prepared.

Most testes twist inward and therefore require outward rotation, often described as opening a book.

However, rotation direction is not universal.

If pain worsens or the testis rises, reverse direction.

More than 360° of torsion can occur, so several rotations may be necessary.

Successful manual detorsion does not eliminate the need for urgent surgery.

Exploration

Detorse the spermatic cord.

Warm the testis and allow reperfusion.

Assess:

• Colour
• Turgor
• Bleeding
• Restoration of perfusion

If viable, perform orchiopexy.

Fix the contralateral testis during the same operation because bell clapper anatomy is commonly bilateral.

Nonviable testis

Perform orchiectomy if clearly infarcted and nonrecoverable.

Do not retain a completely necrotic testis solely because the patient is young.

Neonatal torsion

Extravaginal torsion usually occurs antenatally or perinatally.

Management is individualised, but urgent exploration is particularly important with:

• Acute postnatal torsion
• Bilateral involvement

because preservation of any functioning testicular tissue is crucial.