Define Testicular Torsion. Describe its clinical features and management.

The Concept

Testicular torsion is a twisting of the spermatic cord that occludes the testicular blood supply, causing ischaemia of the testis. It is a true urological emergency because the testis becomes non-viable within about 6 hours of the onset of ischaemia. It occurs mainly in adolescents and young men, and is predisposed to by a congenital 'bell-clapper' deformity (a high investment of the tunica vaginalis allowing the testis to hang and rotate freely).

Clinical Features

There is sudden, severe testicular pain (often with lower abdominal pain), swelling, and nausea/vomiting. Examination shows a tender, high-riding testis that may lie horizontally, an absent cremasteric reflex, and a negative Prehn's sign (elevating the testis does not relieve the pain — in contrast to epididymo-orchitis, where it may).

Management — Do Not Delay

Torsion is a clinical diagnosis, and treatment must not be delayed for imaging — any delay costs the testis. The patient goes for immediate surgical exploration: the cord is untwisted (detorsion) and, if the testis is viable, it is fixed to prevent recurrence; both testes are fixed (bilateral orchidopexy) because the predisposing deformity is usually bilateral. A non-viable testis is removed (orchidectomy).

Differential — the Acute Scrotum

Torsion must be distinguished from the other causes of an acute scrotum — epididymo-orchitis and torsion of a testicular appendage (hydatid of Morgagni). Epididymo-orchitis tends to have a more gradual onset with urinary symptoms and a positive Prehn's sign (relief on elevation), while a torted appendage may show a 'blue dot' sign. However, because missing torsion costs the testis, the safe rule is that an acute scrotum is torsion until proven otherwise, and exploration is preferred to risky delay.

The Bottom Line

Testicular torsion is a clinical, time-critical emergency (the testis dies within ~6 hours) demanding immediate exploration, detorsion and bilateral orchidopexy — never delayed for imaging.

A Note on the 6-hour Window

The emphasis on the 6-hour window reflects testicular physiology: salvage rates are high if detorsion occurs within about 6 hours, fall sharply thereafter, and are poor beyond ~12–24 hours. This is why the pathway is 'explore first, image never-if-it-delays' — a Doppler ultrasound can support the diagnosis where it is genuinely in doubt and immediately available, but it must not postpone surgery in a clinically convincing case. The clock, not the scan, drives management.

Explore within six hours — do not delay for imaging.

• Testicular torsion = twisting of the spermatic cord → testicular ischaemia; emergency (testis non-viable in ~6 h); adolescents/young men; bell-clapper deformity.
• Sudden severe testicular pain, swelling, vomiting; high-riding tender testis, absent cremasteric reflex, negative Prehn's sign.
• Clinical diagnosis — do not delay for imaging.
• Immediate surgical exploration + detorsion + bilateral orchidopexy (fix both); orchidectomy if non-viable.