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Testicular Torsion: A Review

Article  in  Journal of Lower Genital Tract Disease · February 2001

DOI: 10.1046/j.1526-0976.2001.51008.x

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 Testicular Torsion: A Review
Srinivas Pentyala, PhD,† Jacky Lee, BS,* Praveen Yalamanchili, BA,†
Stephen Vitkun, MD, PhD,† and S. Ali Khan, MD*
Departments of *Urology and †Anesthesiology,
School of Medicine, State University of New York, Stony Brook, NY
䊏 Abstract: Torsion of the testis, also referred to as torsion of
the spermatic cord, is a subject of debate among physicians
and surgeons. Testicular torsion is an acute vascular event
causing the rotation of the vascular pedicle of the testis,
thereby impeding the blood flow to the testis and the scrotal
contents. It could be either within or outside the tunica vagi-
nalis. Testicular torsion causes immediate circulatory changes
and long-term sequelae such as testicular function and fertil-
ity. It is considered a surgical emergency, as a delay causes ir-
reversible testicular damage. The diagnosis and treatment of
testicular torsion are discussed in this review, which also illus-
trates an algorithm and a scoring system for the diagnosis and
management of this condition based on current literature. 䊏
Key Words: spermatic cord, testis, torsion
T esticular torsion of the testis was described as early
as 1840 [1], but it has taken a long time for it to be
recognized as a vascular emergency that needs prompt di-
agnosis and treatment. It was not until 1907 when Rigby
and Howard wrote their classic paper on torsion that this
entity gained widespread clinical acceptance [2].
The diagnosis of testicular torsion in a patient with
sudden onset of scrotal pain and swelling in testis
seems straightforward. Failure to diagnose this condi-
tion promptly leads to loss of a testis. The problem is
compounded by a number of conditions having rela-
Reprint requests to: S. Ali Khan, MD, FRCS, FACS, Professor of Urology,
Level 9, Rm 040, Health Sciences Center, SUNY at Stony Brook, Stony
Brook, NY 11794-8093
© 2001 ASCCP, 1089-2591/00/$15.00/0
Journal of Lower Genital Tract Disease, Volume 5, Number 1, 2001, 38–47
tively similar history and findings. These include prima-
rily acute epididymo-orchitis and torsion of the testicu-
lar appendages.
There is no consensus about the precise algorithm to
be followed in cases of suspected torsion. Even an astute
clinician cannot clinically differentiate between testicu-
lar torsion and epididymo-orchitis with absolute cer-
tainty. The traditional evaluation for a patient with sus-
pected testicular torsion has been clinical evaluation
followed by an immediate surgical exploration. Often,
diagnosis of acute epididymo-orchitis is made in the op-
erating room [3]. This dictum has led to unnecessary
surgical intervention, resulting in increased cost and
morbidity. Literature shows that testicular torsion may
decrease fertility; the mechanism for infertility is not
known. There is support for the concept of sympathetic
orchitis with conflicting reports supporting and refuting
this idea [4]. Many investigative methods have been sug-
gested. Few have stood the test of time, and there is no
gold standard investigation with 100% sensitivity, spec-
ificity, and accuracy.
EMBRYOLOGICAL AND CLINICAL ANATOMY
For a thorough understanding of the mechanism and
types of torsion, it is essential to understand the develop-
mental and gross anatomy of the inguinoscrotal structures.
The testis initially develops retroperitoneally, adjacent to
the kidney [4]. At about the third month of intrauterine
life, the gubernaculum testis develops and extends from
the genital tubercle to the inferior pole of the testis via
the inguinal canal. The peritoneum later encircles the
testis completely forming a mesentery, the mesorchium.
The inferior, main part of the gubernaculum attaches to

the scrotal skin pouch, and the minor, superior part dis-
appears [4].
The testis is an oval-shaped structure in adults, mea-
suring 3.8 cm in length, 2.5 cm in depth and 2 cm in
width. The longitudinal axis of the testis lies in the scro-
tum vertically. The testicular parenchyma is composed
of distinct cellular elements responsible for the endo-
crine function and spermatogenesis. The seminiferous
tubules are lined with Sertoli cells that are involved in
spermatogenesis. The Leydig cells are embedded in the
interstitium, outside the seminiferous tubules, and se-
crete testosterone. The epididymis and the lower aspect
of the spermatic cord are attached to the postero-lateral
aspect of the testis by a connecting structure through
which the neurovascular structures enter the testis. This
potential space between the two layers of tunica vagina-
lis has minimal fluid, which facilitates the movement of
the testis in the scrotum by acting as a bursa. The testicular
appendages consist of the appendix testis, appendix epid-
idymis, paradidymis, and aberrant ductules (see Fig. 1)—
all of which are embryological remnants of Mullerian and
Wolffian ducts—and can produce scrotal pain most often
in the pediatric population by undergoing torsion.
The epididymis is a coiled structure. When uncoiled,
it measures approximately 600 cm in length. The epi-
didymis consists of an upper enlarged portion called the
head, which is continuous with the body and the tail.
The tail region proximally becomes the vas deferens.
The testicle is suspended from the spermatic cord like
an object at the end of a rope. The spermatic cord and
its structures lie within the inguinal canal extending
from the deep inguinal ring to the superficial inguinal
ring ending at the posterolateral aspect of the testis. The
contents of the spermatic cord include the vas deferens
and its artery, the testicular artery, the pampiniform
plexus of veins, lymphatic vessels, and the sympathetic
Testicular Torsion • 39
nerves. All of the aforementioned structures are en-
closed in fascial layers derived from the oblique muscles
of the abdomen. Loops of cremasteric muscle encircle
the spermatic cord and scrotum, innervated by the ilio-
inguinal nerve and are responsible for the cremasteric
reflex [4].
The blood supply to the testis consists of the testicu-
lar artery originating from the aorta, the deferential ar-
tery from the inferior vesical artery, and the cremasteric
artery from the inferior epigastric artery. The scrotal
wall is supplied by the pudendal artery, which is not a
content of the spermatic cord and, thus, not involved in
testicular torsion. The venous drainage consists of the
pampiniform plexus, which becomes the testicular vein
at the deep inguinal ring. The right testicular vein drains
into the inferior vena cava and the left testicular vein
joins the left renal vein. The blood supply of the testis
markedly increases at puberty. In children, the small
volume of the testis and scant blood flow makes the
study of the vascular flow phenomenon difficult to as-
sess by duplex Doppler (a diagnostic modality in which
frequency shifts of an ultrasound beam reflected from
moving structures are amplified and presented as sound
by the Doppler instrument accomplishing imaging and
color-encoded imaging at the same time) [5, 6].
ETIOLOGY
Many congenital anatomical abnormalities of the tes-
tis and its adnexae have been considered as the factors
responsible for the causation of torsion. Those include
hypermobile testis [7, 8], loose and abnormal connec-
tions between testis and adnexae [9], and polyorchido-
pathia [10–12]. Normally, the testis is suspended in a
vertical position, but testis lying along a horizontal
plane has been found to increase incidence of torsion,
especially subclinical intermittent torsion [13]. Cryp-
Figure 1. Vestigial structures
involved in torsion.
40 • pentyala et al.
torchid testes have long been recognized to cause torsion
and demonstrated in experimental studies and case re-
ports [14, 15]. Testicular tumor [16, 17] and torsion sper-
matocele [18] predispose in favor of torsion. Anomalous
spermatic cord attachment [19], bifurcation and short
cord [20] have been hypothesized to predispose to tor-
sion. Some of the abnormalities of tunica vaginalis like
capacious tunica vaginalis, “clapper bell deformity” (faulty
mesentery of the testis), and high investment of the tu-
nica have been thought to contribute to testicular [20,
21, 22]. Other factors hypothesized to increase torsion risk
are a voluminous scrotum [19], an elongated globus mi-
nor (body of epididymis) [2], thrombosis of the pampin-
iform plexus veins [23], excessive mobility of the vas
deferens [24], a hyperactive cremasteric reflex [25], mal-
developed gubernaculum testis [26], vascular hamartoma
[27], and previous scrotal surgery and orchidopexy [28].
In addition to these predisposing factors, muscular
exertion in the form of swimming, skating, sexual exer-
tion, sudden flexing of the thighs, and weight lifting
[25], has been reported to precipitate torsion in the
young adults. A recent report suggested that persistent
Mullerian duct syndrome might contribute to develop-
ment of torsion [29]. Reports have indicated that tor-
sion is more likely to occur in cold climates especially in
places with temperatures below 15⬚C and less likely to
occur in hot conditions and summer months [30].
PATHOGENESIS
Torsion results from twisting of the spermatic cord,
which causes ischemic changes such as swelling, degen-
eration, necrosis, and infarction, depending on the de-
gree and duration of twisting. Torsional twisting usually
occurs away from the midline, probably secondary to
the direction of the cremasteric muscle fibers (see Fig. 2).
The degree of the torsion varies from 180⬚ to more
than 720⬚. This variation in torsion contributes to the
variant presentations of acute torsion from severe to
sub-acute and chronic torsion. Torsion blocks both arte-
rial supply and venous drainage. This contributes to hem-
orrhage, edema, ecchymosis, and cellulites. The edema
further results in altered blood flow dynamics to the testis
and accentuates arterial blockage, hypoxia, and gangrene
of the testis [31].
HISTORY
Torsion can occur in any age group but is most com-
mon in 12 to 18-year-olds, with a secondary increased
incidence during infancy. As in any vascular event, the
pain in torsion is of sudden onset, while a typical epi-
didymitis pain is gradual in onset. The presentation of
sudden-onset scrotal pain may vary according to the de-
gree of torsion and its duration. A gradual onset of symp-
toms causes less physician concern and may result in misdi-
agnosis. The patient may complain of awakening from
sleep and may frequently recall the exact time of the onset
of pain. Leape describes two categories of clinical symp-
tomatology in cases of torsion [32]. The first is transient,
intermittent pain that represents subacute, chronic, or in-
termittent torsion. The second is acute testicular and scro-
tal pain, which has two subcategories: early and late
presentation. Early presentation is characterized by an ex-
amination during which the testis and epididymis are pal-
pated as separate structures, and late presentation has ob-
scured testis and epididymis from inflammation. Other
features may include scrotal erythema, nausea, vomiting,
or fever. The patient may relate a history of scrotal trauma,
lifting of heavy weights, undescended testicle with previous
orchiopexy, groin mass, hernia, or previous history of tes-
ticular torsion.
PHYSICAL EXAMINATION
After obtaining the patient’s history, examination
should begin from the spine, back, perineum, groin, and
then the scrotal skin. An abdominal examination should
be performed, keeping in mind other etiologies that
could give rise to similar symptomatology.
Scrotal examination includes visualization and gentle
palpation. The scrotal examination begins with the nor-
mal side first because pain and a reactive hydrocoele can
interfere with the physical assessment of the intrascrotal
contents on both sides. Also, the normal testis serves as
a control. The scrotal skin is inspected for erythema, dis-
coloration, swelling, ulceration, gangrenous patches, and
disparity between the hemiscrotums. In torsion of more
than 12 hours, the skin may be erythematous, swollen, or
discolored.
The position of the testicle and its adnexae are impor-
tant in the examination for torsion. The testis lies along
its vertical axis and the epididymis is closely appposed
to its postero-lateral surface. These landmarks are useful
to assess the position of the testicle. An elevated testicle
with a horizontal placement is suspicious for torsion.
The entire testis is tender and swollen in cases of tor-
sion, whereas just the upper pole is tender in cases of
torsion of the appendages. A “blue dot sign” (appendages
undergo torsion and become gangrenous appearing blue
through the wall of scrotum) observed on the scrotum
may be indicative of torsion of the testicular appendages.
The presence of blue dot sign and upper pole tenderness

is virtually a diagnostic character for torsion of the ap-
pendages.
Stroking or pinching the medial side of upper thigh
while observing the scrotum assesses the cremasteric re-
flex. The presence or absence of cremasteric reflex is im-
portant. Absence of the reflex is indicative of testicular
torsion, especially in the pediatric population from ages
30 months to 12 years [33, 34]. Normally, this contrac-
tion of the cremasteric muscle fibers results in the eleva-
tion of ipsilateral hemiscrotum. Previous herniorrhaphy
or inguinoscrotal surgery may alter this reflex. It may be
absent in teenagers and young adults [34]. Transillumi-
nation of the scrotum should be routinely performed to
differentiate a solid testicular mass from hydrocele. A tor-
sion knot can sometimes be palpated and, if necessary,
can be localized using ultrasonography [35]. The inguinal
region should be examined for spermatic cord tenderness,
cough impulse (movement of testicles when coughing), or
fascial defects suggesting the presence of hernia.
If tenderness at the internal inguinal ring is observed,
examination of inguinal canal contents to exclude a
small nonpalpable incarcerated inguinal hernia must be
performed because an incarcerated hernia can produce
mimicking symptoms by circulatory arrest of venous re-
turn in the spermatic cord. The presence of one-sided
swelling is suggestive of hernia.
Testicular Torsion • 41
Figure 2. Direction of the twist.
The presence of severe pain and hydrocele interferes
with the physical assessment of the intra-scrotal con-
tents, especially in children. A spermatic cord block us-
ing a local anesthetic may facilitate the examination.
This is performed by infiltration of 2% xylocane around
the spermatic cord at the external ring where the ilio-
inguinal and genitofemoral nerves are anesthetized. In
addition, this procedure may be used for the aspiration
of peritesticular fluid from the scrotal contents if fluid
is serosanguinous. Prehns’ sign is the relief of scrotal
pain upon elevation of the scrotum [36]. Though posi-
tive mostly in epididymo-orchitis and mostly negative in
cases of torsion, it is unreliable to diagnose epididymitis.
Systemic signs such as fever and leukocytosis are associ-
ated with epididymitis, but are not completely reliable
diagnostic indicators. Rectal examination completes the
examination.
ADJUNCTIVE TESTING
Testicular torsion usually is diagnosed by history and
clinical examination. When the presentation is atypical,
investigative methods are used to confirm the diagnosis.
Without adjunctive diagnostic intervention, the diagno-
sis may be incorrect in more than 50% patients. Several
techniques have been used in the past for accurate diag-
nosis. A radiolabel scan of the testes looking for Xe-133
42 • pentyala et al.
clearance had been proposed as an innovative method
[37, 38], but the sensitivity falls far below the expecta-
tions. Using RP-30A as a new radioactive marker has
been tested in the study of testicular blood flow. It was
reported to be better than Tc-99m for detecting early
cases of testicular torsion [39], but detailed studies must
be performed with this technique to ascertain the clini-
cal application. Blood chemistry, such as increase in cre-
atine phosphokinase, also has been used to support the
early diagnosis [40]. Scrotal thermography was used to
distinguish between inflammation and torsion, but the
results were too variable [40]. Also, testicular oximetry
has been used to study the testicular perfusion and cellu-
lar viability in experimental animals [41].
Gray scale sonography is a sensitive tool for the diag-
nosis of focal intrascrotal pathologies and also can be
used for differentiating testicular disease from appen-
diceal diseases [42]. It is easily available in the physi-
cian’s office, rapid, safe, non-invasive, and without radi-
ation hazard. Preinvestigative preparation is not required
to perform ultrasound. It may distinguish between testic-
ular, paratesticular, and scrotal lesions. At high resolu-
tions, it can distinguish between solid, cystic, and com-
plex pathologies [43]. Spiral twist of the spermatic cord
vessels and reactive hydrocele appear to be two reliable
signs indicative of torsion on B-mode ultrasonography.
Presence of “torsion knot” (twist in the spermatic cord)
on an ultrasound image has been proposed to be a patho-
genic sign of torsion of the spermatic cord.
Ultrasound may be used to assist aspiration of peri-
testicular fluid for examination. Serosanguinous fluid
suggests torsion of the testis and appendages. Aspirating
clear fluid usually suggests epididymorchitis. Heteroge-
neous testicular tissue with increased size of the testis
may be observed in neonatal torsion [3, 44]. In neo-
nates, a spherical testicular mass may be considered a
sign of torsion [44], but in adults the presence of hetero-
geneous areas is not pathognomonic of testicular torsion
[45, 46].
Low sensitivity and high false negative rates limit the
use of gray scale ultrasound for the diagnosis of testicu-
lar torsion [42, 44]. It cannot differentiate subacute tor-
sion from testicular tumor or epididymo-orchitis [3].
Gray scale sonography is useful and sensitive in diag-
nosing testicular appendicular torsion. A pathogno-
monic, echo-producing lesion at the superior pole of the
testis is seen in majority of these cases [47].
The shortcomings of gray scale sonography led to the
development of color Doppler ultrasonography (CDU).
It may be performed without anesthesia or sedation.
Transducers of different frequencies with phased and
linear scanners are used to enhance visualization of vas-
cular perfusion and gray scale anatomy [32, 48, 49].
During the CDU examination, the scrotum usually is
supported in a sling to hold it steady. Examination con-
sists of imaging with gray scale ultrasound of the con-
tralateral side first, followed by perfusion Doppler study
of the testicles. This sequence is repeated in the torsed
testis, with the contralateral normal side serving as a
control. CDU can be used to visualize the anatomy of
the testis, paratesticular structures, tunicae, and the
blood vessels as real time images. In neonatal torsion,
CDU may be used to estimate the time elapsed since the
occurrence of intrauterine torsion [50]. A relatively short
duration of torsion is characterized by mixed echogenic-
ity. Prolonged intrauterine torsion shows calcification
and a hypervascular ring of tunica with a hypodense cen-
ter [50].
CDU is helpful in outlining small [49, 51] and medi-
astinal arteries in about half of the normal testes [52],
which is a definite advantage over angiography, which
fails to produce a cross-sectional image of the arteries
[52]. Pulsed Doppler sonography with mechanical sec-
tor scanners is a better method than CDU for the diag-
nosis of torsion of the testis [6], but this technique stud-
ies only the testicular arteries and omits the scrotal,
paratesticular, and testicular surface vessels. CDU also
has its shortcomings, including motion artifact [5],
showing incomplete torsion, delayed presentation to the
clinician, inability to visualize the blood flow in preado-
lescent males [5,6], hyperemia observed in spontaneous
or manual detorsion [5], and occasional cases showing
normal or subnormal blood flow to the testis and in-
creased flow to the paratesticular structures mimicking
epididymo-orchitis [5].
Scrotoscopy under local anesthesia has been per-
formed in rats to visualize the presence of testicular tor-
sion by direct visual examination [53]. From prelimi-
nary reports, scrotoscopy appears simple, accurate, fast,
and minimally invasive.
Magnetic resonance imaging (MRI) is a noninvasive
technique that does not involve ionizing radiation. It is
based on the specific arrangement of molecular nuclei
on exposure to three magnetic fields. MRI produces
good tissue contrast. Changing the instrument parame-
ters varies the tissue contrast. In T1-weighted images,
testis yields a mediocre, homogeneous image, whereas
T2-weighted imaging generates the same characteristics
as fat tissue. T1 and T2 imaging can be of special help in
the localization of the cryptorchid testis, inguinal lymph

nodes, the presence and nature of fluid in the scrotal sac,
and the contents of the spermatic cord [54]. In cases of
testicular torsion, the distortion of the chordal contents,
which leads to torsion knot and whirlpool, may be ob-
served [55].
On P-31 spectroscopy, diminished blood supply to
the testis is observed in cases of torsion, and an attenu-
ated adenosine triphosphate peak and enhanced inor-
gonic phosphate peak is seen, thus serving as a compli-
mentary method for the diagnosis of torsion [54]. MRI
sensitivity has been reported to be 88% [56] and pro-
posed to be a good diagnostic tool for torsion, correlat-
ing well with hypoxic injury and time elapsed [57].
Diagnostic modalities such as radionuclear scanning
introduced by Nadel and co-workers [58] accurately
measure the vascular flow, obviating the need for unnec-
essary surgery [59]. Scintigraphy can be used to measure
bilateral equal arterial perfusion in the testis. A nuclear
imaging scan to examine the vascular flow to the testis
and involves giving the patient a bolus intravenous in-
jection of Tc-99m–labeled dye. In pediatric patients, the
amount is calculated on the basis of weight in their age
group. Scintillation counts are recorded with a gamma
camera. Sequential images over time are taken and sup-
plemented with a stationary image to visualize the blood
pool activity. The most prominent finding in torsion is a
cold area, meaning it is devoid of any radioactivity. The
flow pattern differentiates the cold area from inflamma-
tory pathologies such as epididymo-orchitis, where in-
creased flow to the scrotal contents is observed. Scinitg-
raphy is particularly useful in adult cases where a
diagnosis of torsion is missed [60, 61], as well as cases of
chronic torsion [62], halo signs [63], recently increased
scrotal size [64, 65], and in post-orchipexy patients [66].
Prolonged torsion may show areas of hyperperfusion
around a hypovascular testis because of increased blood
flow to the dartos muscle [67]. Scintigraphy of the testis
may be useful in the diagnosis of testicular abcess, poly-
orchidism [10], and scrotal trauma. Cases of anaphylac-
toid purpura [68] and hip pain causing diagnostic con-
fusion with torsion can be differentiated by scintigraphy
[69]. Some studies have claimed it to be a better diag-
nostic modality than CDU [70]; however, scintigraphy
is not infallible. Its utility is limited for cases of small tes-
ticular size, missed torsion, chronic torsion [71], and
epididymal cyst [72]. If perfusion of the testis is to be
studied after detorsion, a second injection is required
[73]. Scintigraphy shows only the vascular flow to the
testis [74] and often fails to correlate the clinico-patho-
logic anatomy.
Testicular Torsion • 43
DIFFERENTIAL DIAGNOSIS
Testicular torsion has many clinical features. The dif-
ferential diagnosis includes many other conditions, some
of which are common and uncommon causes of scrotal
pain and swelling. In the past, these causes have been
mistaken for testicular torsion because of the clinician’s
failure to consider these possibilities. The differential di-
agnosis can be divided into categories of scrotal and in-
trascrotal pathologies (see Table 1).
TREATMENT
The treatment of testicular torsion relies on early rec-
ognition. The critical time for testicular salvage has been
variably reported at about 6 hours [75]. The symptoms
in patients with salvaged twisted testicle were present
for an average of 5.5 hours as compared to 42 hours in
those who underwent orchiectomy for a nonviable tes-
tis. Late presentation to the clinician is one of the main
causes of delayed treatment in torsion leading to or-
chiectomy. Health education of the patients and general
physicians and early referral to hospital may reduce de-
lay in diagnosis and treatment. The ischemic process in-
volved in testicular torsion must be diagnosed before ir-
reversible injury to the testis occurs.
In cases with strong clinical suspicion of testicular
torsion, treatment should be instituted promptly. There
is a general consensus to preserve the testicle, though it
is not possible to do so in all the cases. The use of sper-
matic cord block with a local anesthetic has been advo-
cated [76] in patients with suspected testicular torsion to
facilitate examination, sonography, and then detorsion,
but this technique has been underutilized.
The combination of applying ice packs to the scrotum
and cord block facilitates physical diagnosis and the tem-
porary relief of pain caused by torsion. Local hypother-
mia induced by the application of ice packs probably delays
ischemic injury [77, 78]. Immediate efforts to manually
detorque the testis are only possible with a spermatic cord
block that provides sufficient analgesia. Local anesthesia
also facilitates detorsion [76], and a report has advocated
the use of naloxone before detorsion [79].
Manual detorsion of the testis is based on the fact
that torsion of the testis occurs away from the midline.
Therefore, the direction of detorsion should be toward
the midline opposite to the directions of torsion. Detor-
sion is performed by gently grasping the testicle between
thumb and the index finger and rotating the testis verti-
cally, towards the midline [4]. If manipulation causes
greater pain, the testis should be moved in the opposite
44 • pentyala et al.
Table 1. Pathologies Depicting Differential Diagnosis of
Testicular Torsion
Scrotal:
1. Idiopathic edema of the scrotum
2. Traumatic fat necrosis
3. Cellulitis
4. Acute scrotal gangrene
5. Fulminating intertrigo
6. Scrotal abcess
Testicular:
Infective
1. Epididymo-orchitis
2. Mumps orchitis
3. Salmonella enteridis orchitis
Neoplasms
1. Bleeding into testicular tumor
2. Myofibroblastic pseudotumor
3. Torsion of tumor of the testis
Miscellaneous
1. Testicular microlithiasis
2. Polyorchidopathia
3. Ischemic necrosis
4. Traumatic dislocation of the testis
Appendages:
1. Torsion of testicular appendages
2. Epididymal dirofilariasis
direction. If the patient does not experience pain relief
from the detorsion, then immediate surgical exploration
is indicated. Manual detorsion, when successful, is not
the end of road, but further treatment to ensure that tes-
tis stays in position is needed for both the testis, as the
anatomical risk factors for torsion are bilateral.
Manual detorsion cannot be performed if the testis is
obscured secondarily to scrotal wall thickening, inflam-
mation, or reactive hydrocoele. If the torsion is of a
long-standing duration, then manual detorsion will be
ineffective, as will the operative detorsion. If there is any
uncertainty in the diagnosis, exploration of the scrotum
is indicated. A patient with an unsuccessful detorsion
must be returned to the operating room for exploration
resulting either in salvage of the testicle with bilateral
orchiopexy with a nonabsorbable suture or orchiectomy
when the testicle is gangrenous.
A duplex Doppler-guided detorsion of the testis will
give immediate relief of pain and detorsion if blood flow
to the testicle is reestablished. Furthermore, it will re-
lieve the venous congestion and will reverse ischemia in
an even more expeditious manner than surgical explora-
tion. Use of a real-time duplex Doppler in the detorsion
maneuver confirms the restoration of arterial blood
flow and venous drainage to the testicle. After a success-
ful detorsion is confirmed by duplex Doppler ultrasound,
Tunics:
1. Rupture of tunica albuginea
2. Cremasteric spasms and testodynia
3. Rupture of hydrocoele
4. Torsion of spermatocele
5. Acute hydrocele
6. Pyocele
Systemic Conditions:
1. Henoch-Scholein purpura
2. Familial Mediterranean fever
3. Polyarteritis nodosa
4. Thromboangitis obliterans
5. Hypersensitivity angitis
Abdominal and Retroperitoneal:
1. Incarcerated strangulated hernia
2. Neonatal adrenal hemorrhage
3. Tumors of the pancreas
4. Acute appendicitis
5. Hemoperitoneum
Spermatic cord:
1. Infarction of spermatic cord
2. Thrombophlebitis of varicocele
3. Spermatic cord hematoma
Iatrogenic:
1. Iatrogenic torsion of testis
2. Laparoscopic inguinal herniography
the patient must have surgical exploration immediately
and undergo bilateral orchiopexy. The surgical explora-
tion also will confirm the effectiveness of the duplex
Doppler-guided detorsion, as well as provide the oppor-
tunity to perform the necessary bilateral orchiopexy.
Newer techniques such as atraumatic scrotal pouch or-
chiopexy [80], eversion of the tunica vaginalis [81], and
fixation of the testes to the median scrotal wall have been
proposed as alternatives of traditional orchiopexy [82].
Surgical exploration of torsion should confirm the
diagnosis and allow assessment of viability. Viability
should be checked by assessing color, pulse, and a lack
of active bleeding from the incision of testis. A fluores-
cent dye study can be used to confirm the presence or
absence of ischemia in uncertain cases. Furthermore, an
incision of the tunica albuginea can be performed to
confirm ischemia.
Irreversible ischemia from torsion of the testis will re-
sult in a necrosis requiring orchiectomy. If this unfortu-
nate event occurs, it is essential that the patient be of-
fered placement of a testicular prosthesis for aesthetic
and psychological reasons. It is important to emphasize
to all patients with orchiectomy or bilateral orchiopexy
that fertility and testosterone production is usually pre-
served with one testicle. A test of the serum testosterone
levels in the postoperative period may be conducted to
 Testicular Torsion • 45

Table 2. Scoring System for Diagnosis of Testicular Torsion

Testicular
Examinations Descriptions Torsion Epididymitis Scores

1) History Sudden onset of scrotal pain with exact recall of time 5* 0

Gradual onset of pains 0 0
Unsure 4 4
2) Cremasteric reflex Present 0 0
Absent 1 0
3) Position of the contralateral testis
in the scrotum Horizontal 1 0
Vertical 0 0
4) Ultrasound-guided needle aspiration
of hydrocoele fluid Serosanguinous aspirate 1 0
Clear aspirate 0 0
Not done 1 1
5) Duplex Doppler ultrasound Peak systolic velocity same for both testis 0 0
Decreased peak systolic velocity or absent blood flow 1 0
Not done 1 1
OR
6) Testicular scan Both testis normal uptake 0 0
No blood flow 1 0
Nondiagnostic 1 1
Not done 1 1
Total scores

*A score of 6 or more suggests testicular torsion; scrotal exploration is mandatory.

reassure the patient. The patient should have a semen
analysis three months after surgery to assess the sperm
count, with subsequent follow-up if the initial sperm pa-
rameters are abnormal.
CONCLUSION
The management and treatment of acute testicular
pain has often been variable and dependent on the prac-
tice routine of the individual urologist. Acute testicular
pain has often been misdiagnosed because of the similar-
ity in presentation and physical examination between
epididymo-orchitis and testicular torsion—both of which
require different therapeutic steps. The wide variety of
physical findings and characteristic diagnostic tools re-
quire a systematic algorithm to correctly diagnose the pa-
thology. Such an algorithm has been devised at our insti-
tution (see Table 2).
In conjunction with the scoring system for the diag-
nosis of suspected testicular torsion (scrotal exploration
being mandatory with a score of 6 and higher), the treat-
ment algorithm was designed to provide a step-by-step
process involving the therapy of acute scrotal pain. The
management algorithm designed is not to be considered
a standard, but should aid the physician in detailing
manual detorsion and scrotal exploration. In addition
to the more traditional maneuvers, this algorithm incor-
porates the use of the spermatic cord block, aspiration
of the reactive hydrocele fluid, and attempted manual
detorsion with duplex Doppler ultrasound guidance.
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