Testicular Torsion

Information

Testicular torsion occurs when there is twisting of the testicle on the spermatic cord leading to disruption of the vascular supply. If left untreated, this can cause ischaemia and death of the testicle. Predisposing factors include a ‘bell clapper’ deformity where the testicle is more mobile and therefore at higher risk of twisting, and trauma in a minority of cases.

Clinical Features and Epidemiology:

• Age: commonly affects pubertal boys.
• Acute Onset of Pain: severe, unilateral scrotal pain that occurs suddenly and is constant.
• Associated Symptoms: nausea, vomiting, lower abdominal pain.
• Physical Exam: affected testicle may appear swollen and red. The testicle may be elevated compared to other side (high riding) and have an absent cremasteric reflex (no lifting of the testicle when stroking the upper inner thigh). Pain is severe across whole testicle on palpation.
• Time is critical – surgery should ideally occur within 4 hours of onset.

Differentials:

• Torsion of the testicular appendage aka hydatid: less severe pain at rest but is still very tender on palpation. Otherwise well, often no associated symptoms. Characteristic ‘blue dot’ on examination (subtle dark blue hue seen through scrotum, most noticeable in pale skin tones). Pain is worse in upper pole of testicle. Commonly affecting pre pubertal boys.
• Epididymitis: pain develops gradually over hours to days. Often associated with urinary symptoms such as painful urination or discharge. On palpation pain is worse over epididymis rather than testicle.
• Inguinal hernia: unilateral swelling of the scrotum that is full. Should be soft and reducible. If firm and very painful see page on Incarcerated Hernia.
• Hydrocele: painless swelling of the testicle. Will transilluminate on examination. Often associated with viral illness in younger children and will self-resolve. Can feel above lump. See page on Scrotal Hydrocele.