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160 Review article

Testicular torsion and the acute scrotum: current emergency

Anthony Taa, Frank T. D’Arcya, Nathan Hoaga, John P. D’Arcyd and
Nathan Lawrentschuka,b,c

The acute scrotum is a challenging condition for the treating wary of younger males presenting with the acute
emergency physician requiring consideration of a number of scrotum. European Journal of Emergency Medicine
possible diagnoses including testicular torsion. Prompt 23:160–165 Copyright © 2016 Wolters Kluwer Health, Inc.
recognition of torsion and exclusion of other causes may All rights reserved.
lead to organ salvage, avoiding the devastating functional European Journal of Emergency Medicine 2016, 23:160–165
and psychological issues of testicular loss and minimizing
unnecessary exploratory surgeries. This review aims to Keywords: acute, pain, review, scrotal, testicular, torsion

familiarize the reader with the latest management a

Urology Unit, Department of Surgery, University of Melbourne, Austin Health,
strategies for the acute scrotum, discusses key points in Olivia Newton-John Cancer Research Institute, cPeter MacCallum Cancer
Centre, Melbourne and dEmergency Department, Austin Health, Heidelberg,
diagnosis and management and evaluates the strengths Victoria, Australia
and drawbacks of history and clinical examination from an
Correspondence to Nathan Lawrentschuk, MB, BS, PhD, FRACS, Urology Unit,
emergency perspective. It outlines the types and Department of Surgery, University of Melbourne, Austin Health, Australia
mechanisms of testicular torsion, and examines the current Tel: + 61 9496 5000; fax: + 61 9457 5829; e-mail:

and possible future roles of labwork and radiological Received 1 April 2015 Accepted 6 July 2015
imaging in diagnosis. Emergency departments should be

Introduction associated with organ loss. Poorly managed TT is the

The acute scrotum in children and younger men is a third most common cause of malpractice cases in ado-
challenging condition for emergency physicians, often lescent males presenting to emergency departments [2].
hijacked by the term ‘potential testicular torsion’ in Delayed presentation contributes towards the risk of
recognition of the urgency to treat and not miss this time- organ loss with a TT; thus, emergency physicians need to
critical condition. However, the acute scrotum should be aware of the current management standards and the
remain just that, allowing physicians to consider all role of early referral where TT is on the list of differ-
potential diagnoses representing a constellation of entials for an acute scrotum.
symptoms and signs causing pain in the scrotum. In such
situations, the acute scrotum may be because of testicular Epidemiology
torsion (TT), but a careful assessment of history and The causes of an acute scrotum vary with age (Table 1).
examination will elucidate many other potential causes. A bimodal peak in the incidence of TT is observed
Understandably, the spectre of a missed TT drives many beginning in the neonatal period and early adolescence.
to identify TT as a potential diagnosis even if low on the Most boys who present with an acute scrotum (∼50%)
list of differentials, making referrals to surgical teams will have torsion of the appendix testis (TAT). However,
almost inevitable, perhaps driving explorations that are around 13–20% will have TT, with epididymo-orchitis
sometimes unnecessary. Accepting that imaging does not the most common of the other contributing conditions
hold the key to delineating the acute scrotum, a heavy [1,4–6]. Other conditions to consider in the differential
reliance on history and physical examination is often diagnosis range from mumps orchitis, haematoma, renal
required. The aim of this review is to outline presenta- colic, appendicitis and strangulated inguinal hernias
tion of the acute scrotum focusing on TT, the diagnosis and rarities such as the scrotal manifestations of
that should not be missed.

Torsion of the testis is a common condition that accounts Table 1 Age distribution of the causes of an acute scrotum seen at
for ∼ 20% of paediatric patients presenting to the emer- surgical exploration [3]
gency department with acute scrotal pain, with torsion of Age group Testicular torsion Torted appendix Epididymo-orchitis
the testicular appendix representing the most common (years) (%) testis (%) (%)

aetiology [1]. Early presentation and recognition of key 0–11 6.6 62 6

12–16 52 32 3
symptoms and signs are paramount in minimizing the 17–40 48 5 27
potentially devastating psychological and cosmetic issues
0969-9546 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MEJ.0000000000000303

Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

Testicular torsion and the acute scrotum Ta et al. 161

Henoch–Schonlein purpura and communicating haema- In the majority of cases, rotation of the testes initially
toceles following abdominal trauma [7,8]. compromises venous return. However, as time progresses
and oedema ensues, arterial flow is reduced or occluded
Age of presentation can vary, but the age at which boys
[14]. Although the majority of TT occurs in a medial
are most commonly affected with TT is between 12 and
direction, several studies have shown torsion in a lateral
18 years, with a peak between 13 and 16 years [1,5,9]. In
direction in up to 29–33% of cases [9,16].
a retrospective analysis of 115 boys with an acute scro-
tum, of the 83 patients with TT, only 7% occurred in The degree of testicular rotation varies according to the
boys under the age of 11 years [10]. Other series of the literature. One retrospective study of 200 paediatric boys
acute scrotum show a peak incidence of torsion of the with TT showed a higher degree of rotation in non-
testicular appendix of around 10–11 years of age [1,3]. salvageable (managed with orchidectomy) versus sal-
vageable testes (median 540 vs. 360°) [9]. However, the
authors also noted that testicular infarction can occur with
Anatomy and mechanism of infarction rotation as mild as 180°.
TT can occur in several different ways, and can be
TAT results in infarction of the mesothelial remnant of
classified as intravaginal, extravaginal or mesorchial. A
the Müllerian (paramesonephric) duct on the super-
slight preponderance in left-sided TT has been noted in
olateral surface of the testis. The appendix of the epidi-
some series, although the mechanism for this is unclear
dymis (remnant of mesonephric duct) has also been
reported to twist [17]. This results in a hard mass on the
Intravaginal torsion most often occurs because of a con- surface of the testicle with point tenderness and a ‘blue
genital malformation of the processus vaginalis as the dot’ sign (a subtle blue-coloured mass viewed through
testis descends into the scrotal sac. This type of torsion the scrotal skin on examination). TAT occurs more
accounts for the majority of TTs, and is most often seen commonly in the prepubertal age group [3].
in pubertal boys, where rapid growth and increased vas-
culature may be a precursor. Under normal circum-
stances, the tunica vaginalis does not fully extend around
the testicle and attaches to the posterolateral scrotal wall,
A careful assessment of history is vital in the assessment
allowing the testis to remain suspended in an upright
of the acute scrotum. The classical presentation for TT is
vertical position. However, in up to 12% of boys, the
sudden-onset severe unilateral pain. The pain, being
tunica vaginalis completely envelopes the testis and
ischaemic in nature, typically requires opiate analgesia.
epididymis, resulting in a ‘bell-clapper’ testicle that is
Persistent pain after opiate analgesia should lead to sus-
more horizontally oriented, with greater ability to rotate
picion of TT. The pain may be accompanied by a history
freely around an axis [12].
of previous bouts of intermittent testicular pain, which
Extravaginal torsion, which is rare, occurs during the likely represents episodes of torsion and detorsion.
perinatal period and is because of a different mechanism.
The duration of symptoms before presentation can vary
It occurs during descent of the testes into the scrotum
significantly, ranging from several hours to several days.
before scrotal investment of the tunica vaginalis has
However, patients with TT tend to have a shorter
taken place, where complete adhesion to the surrounding
duration of symptoms before presentation [1,18]. Early
tissues is usually completed by 6 weeks of age [13].
presentation in cases of TT is associated with higher
Twisting of the processus vaginalis and its contents
likelihood of salvage.
results in necrosis and absence of blood flow within the
testis, epididymis and cord. If torsion has occurred in the The presence of nausea and vomiting, caused by reflex
prenatal period, the clinical presentation is a neonate stimulation of the coeliac ganglion, can be a useful clue in
with unilateral or bilateral blue nontender hard masses in diagnosing TT, but incidence varies significantly in the
the scrotum [14]. However, if it occurs in the postnatal literature. Some series report nausea and vomiting in
period, the presentation is more classic, with acute 57–69% of patients with TT, with positive predictive
inflammation and erythema in a previously normal neo- values for nausea and vomiting as high as 96 and 98%,
natal scrotum, requiring exploration and fixation [13]. respectively, compared with 8 and 4% in TAT and none
in epididymo-orchitis [9,10]. Other series have shown
Mesorchial torsion is exceedingly rare and has an atypical
that nausea and vomiting do occur in torsion of the tes-
presentation. It occurs because of anomalies in the
ticular appendix and epididymo-orchitis, but the com-
mesothelium that covers the anterior half of the testis and
plaint is much rarer [1,18].
suspends it from the vasculature and epididymis. When
the attachment is narrow, mesorchial torsion can occur Dysuria is an uncommon complaint in TT, and its pre-
when there is a twist in the tissue overlying the vascu- sence likely indicates an alternate diagnosis such as
lature (anteriorly) between the epididymis and the par- epididymo-orchitis [19]. A history of trauma should not
ietal tunica vaginalis [15]. discount the possibility of TT. Although the large

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162 European Journal of Emergency Medicine 2016, Vol 23 No 3

majority of cases of TT are unprovoked, 4–10% of pathognomonic of another cause, may be used to help
cases have been reported to occur in the setting of trauma place TT as a less likely diagnosis of the acute scrotum.
Laboratory investigations
Physical findings A urinalysis should be carried out as part of the routine
In a normal scrotum, the testis is mobile, and the cord and work-up. A positive dipstick result is more likely to be in
epididymis are palpable posterior to the testis. In TT, the keeping with epididymitis, especially in the setting of
affected testis is usually riding high. The globe of the dysuria and other features of a urinary tract infection.
testis is very tender, and venous distension and transu- However, a positive result does not exclude torsion,
date often result in a larger testis compared with the which can occur in rare instances [1].
contralateral and unaffected testis. Focal areas of ten- Routine blood tests may not need to be performed if the
derness in the superior testis or caput epididymis may clinical diagnosis is highly suspicious of TT, but may be
indicate a torted testicular appendix or epididymitis. useful in identifying other causes of the acute scrotum.
However, anatomical landmarks may be obliterated as An elevated C-reactive protein and white cell count for
oedema and erythema increase in later stages of torsion. example would be consistent with infection [5].
Assessment of the cremasteric reflex is important, and its
absence is generally considered one of the more reliable Role of imaging
physical signs of the presence of TT. The reflex is eli- High-resolution ultrasound (HRUS) with colour-flow
cited by stroking or pinching the medial thigh. Doppler ultrasonography (CDS) and radionuclide ima-
Contraction of the cremasteric muscle results in elevation ging can provide information on blood flow to the testes
of the testis, and the sign is considered positive if there is [25]. Absent arterial flow within the suspect testis on
movement of less than 0.5 cm on the affected side with a CDS is indicative of TT. However, the availability of
movement greater than 0.5 cm on the unaffected side. ultrasound in the emergency setting will vary between
One series of 245 boys presenting with acute scrotal institutions, and the results will be dependent on the skill
swelling reported absence of the cremasteric reflex in and experience of the radiographer or the radiologist.
100% of patients with torsion [21]. Similarly, in a large
Many studies advocate CDS as a useful tool in excluding
retrospective study of over 1200 cases over an 18-year
torsion and confirming other testicular pathology.
period, 94% of boys with TT had an absent cremasteric
However, the accuracy of CDS in diagnosing TT can
reflex [18]. Although the sign can be observer dependent
vary significantly in the literature. In a recent retro-
and published reports have shown an intact cremasteric
spective study of 298 patients who underwent CDS,
reflex in cases of TT, its absence should raise a sig-
followed by surgery regardless of the result, CDS was
nificant clinical suspicion of the diagnosis [5,22,23].
shown to have a sensitivity and specificity for TT of 96.8
The epididymis may be located medially, laterally or and 97.9%, respectively [5]. Positive and negative pre-
anteriorly, depending on the degree of torsion, but may dictive values were 92.1 and 99.1%, respectively. Other
appear normally located if there is 360° torsion, or may be studies have also shown similarly high sensitivity
difficult to palpate in a significantly oedematous scrotum. (95.7–100%) and specificity (85.3–100%) for CDS in
A reactive hydrocoele may be present, as well as scrotal diagnosing TT [26–28]. However, CDS can be inaccurate
oedema. and false negatives can occur, especially in cases of early
TT, intermittent torsion or incomplete torsion of the
A well-performed clinical examination may not reliably
spermatic cord. Several studies have reported arterial
exclude TT as a differential diagnosis and avoid scrotal
flow in affected testes, which were subsequently shown
exploration, but should raise significant concern where
to be torted at surgery [29,30]. Thus, delaying or avoiding
TT is likely and expedite management. Several studies
surgery in a patient with torsion and a false-negative
have shown that the most reliable physical signs of TT
ultrasonography can result in a missed diagnosis of TT;
include (a) a high-riding testis, (b) absent cremasteric
hence, many treating clinicians prioritize a strong clinical
reflex and (c) an anteriorly rotated epididymis or abnor-
suspicion over radiological findings in the decision of
mally oriented testis [18,19,24].
whether or not to perform scrotal exploration.
A febrile patient or erythema of the scrotum with or
HRUS can be used to directly visualize the spermatic
without a small hydrocoele may suggest an infective
cord along its entire length (beginning at the inguinal
process. However, the treating physician should be aware
canal to the posterosuperior border of testis) and assess
that these signs may be superimposed on an already
for any degree of twisting. In a retrospective study of 44
infarcted and necrotic testis.
patients with surgically confirmed TT, CDS detected
In children, other clinical indicators such as easily absent blood flow in only 31 patients (70% sensitivity),
jumping in and out of the bed, a normal appearance but HRUS detected twisting of the spermatic cord in all
lacking distress and a healthy appetite, although not 44 cases [31]. The authors described the appearance as a

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Testicular torsion and the acute scrotum Ta et al. 163

snail shell-shaped mass, separated from the testis, and Management

characterized by an abrupt change in course, size, shape Timing of scrotal exploration
and echotexture below the point of torsion. In a larger TT is a true surgical and time-critical emergency. In
multicentre study of 919 patients with an acute scrotum, patients with testicular pain that is highly suspicious of
HRUS was used to detect spermatic cord torsion in 199 of TT on clinical grounds, urgent exploration should be
208 patients with surgically proven TT (96% sensitivity) carried out with minimal delay, although a risk of ‘over-
compared with 158 confirmed on CDS (sensitivity 76%) treatment’ must be accepted. Some series have reported
[32]. Although HRUS showed a linear cord in the surgical exploration for suspected TT to be unnecessary
remaining 711 patients (99% specificity), the authors did in up to 28% of cases, but in 15% TT was found to be the
show that increasing reliability correlated with the degree cause of acute scrotal pain where the diagnosis was sus-
of experience by the radiologist, and that visualization of pected to be TAT [39].
a spermatic cord twist is difficult in very high or inguinal Scrotal exploration within 6 h of presentation is asso-
testes. ciated with a significantly higher rate of organ salvage. A
large retrospective study showed a median time between
In summary, the role of ultrasound still remains con-
pain onset and presentation to 5 h for cases managed with
troversial in the management of the acute scrotum.
orchidopexy (organ salvage and fixation) compared with
Although ultrasound can reliably detect cases of TT, if
2.2 days for those managed with orchidectomy [9]. After
the clinical diagnosis of torsion is strongly suspected,
12 h of pain, the salvage rate appears to reduce markedly,
there should be no delay to scrotal exploration. but the reported salvage rate varies in the literature. One
Furthermore, if an obvious alternate diagnosis cannot be study of 83 boys with surgically confirmed torsion
achieved, scrotal exploration is recommended. However, showed no salvageable testes after 12 h of pain [10].
ultrasound may be useful in confirming an alternate Other studies have reported a rate of organ loss of
diagnosis when the clinical suspicion of TT is low. 64–90% [1,40,41].
Scintigraphy using technetium 99m pertechnetate can be
used to evaluate the acute scrotum and has been shown Role of manual detorsion
to have superior sensitivity to CDS for detecting TT Manual detorsion can reduce the severity of TT, if tol-
[33,34]. Reduced or absent uptake in the suspect testis is erated by the patient. The classical description is that
seen, with increased uptake seen in conditions such as detorsion should be performed with medial-to-lateral
infection. However, significant disadvantages of this rotation of the testicle, likened to the action of ‘open-
modality include prolonged duration of the investigation ing a book’. If successful, relief from pain is often
compared with ultrasound and lack of availability espe- immediate. As approximately two-thirds of torsions can
cially after hours. be in a lateral direction, manual detorsion in a medial
direction can be performed if the first attempt is unsuc-
More recently, MRI has been advocated in some studies
cessful [9,16]. However, relief of symptoms from manual
as a suitable and accurate test for the diagnosis of TT.
detorsion can be misleading as a degree of torsion may
Although human investigations are limited, several stu- still be present. Residual torsion has been shown to be
dies have shown reduced testicular enhancement on present in 27–32% of patients in whom manual detorsion
dynamic contrast-enhanced subtraction MRI in combi- was attempted before surgery [9,10]. Thus, manual
nation with decreased signal on T2 and fat-saturated detorsion can decrease the degree of ischaemia, but is not
T2-weighted imaging to be a potentially accurate means a substitute for exploration and orchidopexy.
for diagnosing TT and haemorrhagic necrosis, especially
in equivocal cases [35,36]. However, its practice use in
mainstream emergency management is likely to be very Long-term follow-up
limited, given its associated costs, limited availability and Testicular atrophy, as evidenced by reduced volume in
time delay. the affected testis compared with the contralateral testis,
has been shown to occur in up to 12% of patients, with
Near-infrared spectroscopy is a tool that may be promis- increased risk if surgery is delayed for more than 6 h after
ing. It consists of a handheld device applied to the scrotal onset of symptoms [9]. However, parents and patients
skin, is available at the bedside and operates using the should be aware of the risk of testicular atrophy despite
same fundamentals as a pulse oximeter. The tissue earlier presentation as it can still occur in patients pre-
saturation index of the affected testis is compared with senting within 5 h [14]. Long-term studies have shown
the unaffected side, and a discrepancy is suggestive of that early intervention with surgery in patients with TT
torsion. To date, its usage has been limited to case can reduce the risk of poorer semen quality; however,
reports and until it has been proven to be of use in well- even patients diagnosed early and managed with orchi-
designed clinical trials must be considered experimental dopexy to the affected testis can develop impaired
[37,38]. spermatogenesis [42,43].

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164 European Journal of Emergency Medicine 2016, Vol 23 No 3

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