Testicular Torsion: Symptoms, Types, Causes and Treatment

Testicular torsion is a critical medical emergency that can affect males of all ages, but most commonly strikes adolescents. The twisting of the spermatic cord cuts off blood supply to the testicle, putting its survival—and future fertility—at immediate risk. Prompt recognition and intervention are crucial, as every minute counts. This article provides a comprehensive, evidence-based overview of testicular torsion, including its symptoms, types, causes, and treatment options.

Symptoms of Testicular Torsion

Recognizing testicular torsion quickly can mean the difference between saving or losing the affected testicle. While some symptoms are classic, others can be subtle or even misleading, especially in younger patients. Being attuned to the signs is essential for timely care.

Symptom	Description	Typical Age	Key Sources
Pain	Sudden, severe, unilateral scrotal pain	Children, teens	1, 2, 3
Nausea/Vomiting	Often accompanies pain	All ages	1, 2, 3
Swelling	Scrotal swelling, sometimes redness	All ages	1, 2, 9
Abdominal Pain	Especially in young males, can be isolated	Children, teens	3
High-riding Testicle	Testicle sits higher than normal	All ages	1, 2
Absent Cremasteric Reflex	Loss of this protective reflex	All ages	1, 2

Table 1: Key Symptoms of Testicular Torsion

Sudden and Severe Pain

The hallmark of testicular torsion is the abrupt onset of intense, unilateral scrotal pain. This pain often wakes patients from sleep or appears suddenly during activity. It is typically located on one side, correlating with the affected testicle. In some cases, the pain may radiate to the lower abdomen or groin, making diagnosis more challenging, especially in children who might not localize the pain clearly 1, 2.

Additional Symptoms: Nausea, Vomiting, and Swelling

Nausea and vomiting commonly accompany the pain, further distinguishing torsion from less urgent causes of scrotal discomfort. Swelling and redness of the scrotum may follow as inflammation sets in 1, 2, 9.

Atypical Presentations: Abdominal Pain

Young males, especially preteens and teenagers, may present with isolated lower abdominal pain rather than scrotal pain. This can lead to misdiagnosis, as the underlying torsion might not be suspected unless the genitals are carefully examined. Delays in diagnosis in these cases often result in loss of the testicle 3.

Physical Exam Findings

On examination, the affected testicle may appear higher in the scrotum ("high-riding") and may lie horizontally rather than vertically. The cremasteric reflex—a protective retraction of the testicle when the inner thigh is stroked—is often absent, though this is not entirely reliable 1, 2.

Types of Testicular Torsion

Not all cases of testicular torsion are the same. The condition can be classified into several types based on the age at onset and the anatomical structures involved. Understanding these distinctions helps guide both diagnosis and management.

Type	Description	Common Age Group	Key Sources
Intravaginal	Twisting within the tunica vaginalis	Adolescents, adults	2, 5, 7
Extravaginal	Twisting of cord and tunica vaginalis	Neonates	5, 7
Mesorchial	Twist at the mesorchium (rare)	Neonates	5

Table 2: Types of Testicular Torsion

Intravaginal Torsion

This is the most common type among adolescents and young adults. In intravaginal torsion, the testis rotates within the tunica vaginalis, the membrane that surrounds the testicle. A key risk factor here is the "bell-clapper" deformity, where the testis is inadequately anchored, allowing it to twist freely 2, 5, 7.

Extravaginal Torsion

Predominantly seen in neonates and infants, extravaginal torsion involves twisting of both the spermatic cord and the tunica vaginalis. This generally occurs before birth or in the first month of life. Due to its asymptomatic presentation, it is often missed in newborn exams and is rarely salvageable 5.

Mesorchial Torsion

This rare form involves twisting at the mesorchium, the connective tissue between the testicle and epididymis. It is mainly observed in neonates and is less well understood 5.

Causes of Testicular Torsion

While testicular torsion can occur spontaneously, several factors increase the risk. Some are anatomical, while others relate to environmental or genetic factors.

Cause	Description	Risk Factor Group	Key Sources
Bell-Clapper Deformity	Abnormal testicular attachment	Adolescents, teens	2, 7
Age	Peak incidence in adolescence	12-18 years, infants	2, 5, 9
Environmental	Cold temperatures, seasonal variation	All ages	9
Trauma/Activity	Physical activity or minor trauma	All ages	7
Genetics	Familial predisposition, unclear mechanisms	All ages	7

Table 3: Key Causes and Risk Factors for Testicular Torsion

Anatomical Factors: The Bell-Clapper Deformity

The bell-clapper deformity is the single most important anatomical risk factor for testicular torsion. In this condition, the testicle lacks the normal posterior attachment to the scrotal wall, allowing it to swing and rotate freely, much like a clapper inside a bell. This predisposes the testicle to twist on the spermatic cord, especially during rapid movements or minor trauma 2, 7.

Age and Developmental Peaks

Testicular torsion shows a bimodal age distribution: It is most common during the first year of life (as extravaginal torsion) and again between ages 12 and 18 (as intravaginal torsion). This reflects periods of rapid testicular growth and changes in scrotal anatomy 2, 5, 9.

Environmental and Seasonal Triggers

Recent studies have revealed a link between colder ambient temperatures and increased incidence of testicular torsion. The risk appears to peak during winter months, possibly due to cremasteric muscle contraction in response to cold, leading to twisting of a predisposed testicle. This association has been observed across various climates and countries 9.

Trauma and Physical Activity

Although most cases occur spontaneously, even minor trauma or vigorous physical activity can sometimes trigger torsion, especially in those with anatomical predispositions 7.

Genetic and Family History

Some evidence suggests a familial tendency towards testicular torsion, though the exact genetic mechanisms remain unclear. This risk may be related to inherited anatomical variants 7.

Treatment of Testicular Torsion

Immediate intervention is critical to preserve the testicle and fertility. Treatment pathways include both surgical and, in select cases, non-surgical approaches. Advances in supportive care also aim to mitigate long-term damage.

Treatment	Description	Urgency / Goal	Key Sources
Surgical Detorsion & Orchidopexy	Untwisting and fixation of testis; gold standard	Emergent, testis salvage	1, 2, 5, 13
Manual Detorsion	Attempted untwisting by hand in ED	Bridge to surgery	4, 12
Orchiectomy	Removal of non-viable testis	If necrotic	1, 3, 5
Contralateral Orchidopexy	Prevents future torsion on other side	At time of surgery	5, 13
Supportive Therapies	Agents to reduce reperfusion injury	Adjunctive, experimental	6, 10, 11, 14

Table 4: Treatment Modalities for Testicular Torsion

Surgical Detorsion and Orchidopexy

The mainstay of treatment is urgent surgical exploration. If the testicle is found to be viable, it is untwisted (detorsion) and fixed (orchidopexy) to prevent recurrence. Fixation of the opposite testicle is also performed to prevent asynchronous torsion, as anatomical predispositions are often bilateral. The surgical approach may vary, but time to intervention is the most critical factor for testicular survival 1, 2, 5, 13.

Manual Detorsion: A Bridge to Surgery

In settings where immediate surgery is not possible, manual detorsion may be attempted. This involves physically untwisting the testicle at the bedside, ideally guided by ultrasound to assess the direction of the twist. Success is judged by relief of pain and restoration of blood flow on Doppler ultrasound. Even if successful, prompt surgical exploration and fixation are still required to prevent recurrence and confirm viability 4, 12.

Orchiectomy: When Salvage is Not Possible

If the testicle is necrotic or non-viable upon exploration, removal (orchiectomy) is necessary. This is more likely when presentation is delayed or diagnosis is missed, as can happen when the primary symptom is abdominal pain rather than scrotal pain 1, 3, 5.

Adjunctive and Supportive Therapies

Research into pharmacological agents to reduce the damage from ischemia-reperfusion injury—the tissue harm that occurs when blood flow is restored after torsion—shows promise. Agents such as Vitamin D3, topiramate, and other antioxidants have demonstrated protective effects in animal models. These therapies are not yet standard care but may become important adjuncts in the future 6, 10, 11, 14.

Controversies and Long-term Considerations

There is ongoing debate regarding the optimal surgical technique for orchidopexy, and evidence for superiority of any specific method remains limited. Additionally, the impact on long-term fertility and psychological outcomes after testicular torsion—especially in cases requiring orchiectomy—needs further study. Early intervention and education remain the best strategies to improve outcomes 7, 13.

Conclusion

Testicular torsion is a medical emergency demanding rapid recognition and intervention. With potentially devastating consequences for fertility and psychological well-being, awareness and prompt treatment are paramount. Key takeaways include:

• Symptoms: Sudden, severe scrotal pain, often with nausea/vomiting; in children, abdominal pain may be the only sign 1, 2, 3.
• Types: Intravaginal (adolescents), extravaginal (neonates), and rare mesorchial forms 2, 5, 7.
• Causes: Anatomical defects (bell-clapper deformity), age peaks (infancy, adolescence), cold weather, trauma, and possible genetic predisposition 2, 5, 7, 9.
• Treatment: Immediate surgical detorsion and fixation is standard; manual detorsion may be a useful bridge; orchiectomy if the testis is non-viable; emerging therapies aim to reduce tissue damage 1, 4, 5, 12, 13, 14.
• Early action saves testicles: Delays dramatically increase the risk of loss and future fertility issues.

By understanding the warning signs, risk factors, and treatment options, both the public and healthcare providers can help ensure that this urological emergency is managed swiftly and effectively.