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Presentation

History

Extravaginal torsion will most often present as an abnormal scrotal exam in the neonatal period. If the torsion occurred close to the time of delivery, the patient may have a firm and painless testis fixed in the scrotum, with overlying skin discoloration. If torsion is suspected at any time after a normal neonatal exam, investigation should be performed to rule out intravaginal torsion.^[5]

Intravaginal torsion presents as an acute episode of severe unilateral scrotal pain followed by ipsilateral inguinal and scrotal swelling. Onset of symptoms may be related to activity or rest. There may be a history of recent testicular trauma. From 30% to 50% of patients may have a history of preceding intermittent torsion, with episodes of self-limited acute scrotal pain.

Associated symptoms may include nausea and vomiting.^[5]Abdominal pain was noted as the only symptom in 22% of adolescents presenting with torsion. Scrotal examination is therefore recommended in all males presenting with abdominal pain, to prevent delay in diagnosis.^[18]

Physical Examination

In extravaginal torsion, there may be no palpable testis, or there may be a small palpable nubbin within the scrotum or inguinal canal. If the torsion has occurred close to the time of delivery, the patient may have a firm and painless testis fixed to erythematous scrotal skin, with or without surrounding edema.^[5]

In the adolescent presenting with scrotal pain, the physical exam should begin with visual inspection for swelling or discoloration, followed by evaluation of the cremasteric reflex, and finally palpation for assessment of testicular orientation or tenderness. There is often swelling and erythema of the ipsilateral scrotum. The cremasteric reflex is assessed by scratching the superomedial surface of the thigh. A normal response is for the ipsilateral testis to rise cranially due to contraction of the cremasteric muscle fibers in the spermatic cord. The testis may have an aberrant lie within the scrotum, often cranially displaced toward the inguinal ring, and horizontally oriented. Significant generalized tenderness of the affected testis is expected.

The TWIST (Testicular Work-up for Ischemia and Suspected Torsion) score has been developed to assist non-expert physicians to identify those patients most likely to have torsion. This is based on scoring clinical variables including edema, hard mass, absent cremasteric reflex, high-riding testis and nausea vomiting. In those patients demonstrating all of the clinical variables, torsion was noted in 100%.^[19]See Workup.

Example of scrotal appearance in testicular torsion.

View Media Gallery

Intermittent Torsion

Intermitent torsion manifests as episodes of severe scrotal pain of rapid onset that then resolves quickly. Many patients presenting with complete torsion will have a past history of such episodes. Physical examination may identify a horizontal lie of the testis.

Ultrasonographic examination findings vary, but the scan may show decreased blood flow, hyperechogenicity, or hydrocele. Testicular fixation leads to resolution of pain in most patients.

Differential Diagnoses

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Media Gallery

Testicular torsion: (A) extravaginal; (B) intravaginal.
A 17-year-old adolescent boy with a 72-hour history of scrotal pain.
Intraoperative findings in testicular torsion.
Transverse power Doppler image of both testes illustrates an enlarged, avascular left testicle.
Testicular torsion. Transverse color Doppler image of the left groin illustrates an undescended testicle without flow.
Example of scrotal appearance in testicular torsion.
Extravaginal torsion in a newborn.
Intravaginal torsion in a child.

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Author

Ranjiv I Mathews, MD Professor of Urology and Pediatrics, Director of Pediatric Urology, Director of Urology Residency Program, Division of Urology, Department of Surgery, Southern Illinois University School of Medicine

Ranjiv I Mathews, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Illinois State Medical Society, Illinois Urological Society, Indian American Urological Association, North Central Section of the American Urological Association (AUA), Society for Fetal Urology, Society for Pediatric Urology

Disclosure: Nothing to disclose.

Coauthor(s)

Roberta Koeppen, MD Resident Physician, Department of Urology, Southern Illinois University School of Medicine

Roberta Koeppen, MD is a member of the following medical societies: American Medical Association, American Urological Association, Phi Theta Kappa, Sexual Medicine Society of North America

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

Additional Contributors

E Jason Abel, MD Associate Professor of Urologic Oncology, Department of Urology, Associate Professor of Radiology (Affiliate Appointment), Department of Radiology, University of Wisconsin School of Medicine and Public Health; Attending Urologist, William S Middleton Memorial Veterans Hospital

E Jason Abel, MD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, American Urological Association, Harris County Medical Society, Kidney Cancer Association, Society for Basic Urologic Research, Society of Urologic Oncology, Texas Medical Association

Disclosure: Nothing to disclose.

Oreoluwa I Ogunyemi, MD Resident Physician, Department of Urology, University of Wisconsin Hospitals and Clinics

Oreoluwa I Ogunyemi, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Urological Association, National Medical Association

Disclosure: Nothing to disclose.

Madelyn Weiker University of Wisconsin School of Medicine and Public Health

Madelyn Weiker is a member of the following medical societies: American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Acknowledgements

Leslie Tackett McQuiston, MD, FAAP Assistant Professor of Surgery (Urology) Dartmouth Medical School; Staff Pediatric Urologist, Dartmouth-Hitchcock Hospital

Leslie Tackett McQuiston, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and American Urological Association

Disclosure: Nothing to disclose.

Eugene Minevich, MD Assistant Professor, Department of Surgery, Division of Pediatric Urology, University of Cincinnati

Eugene Minevich, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association

Disclosure: Nothing to disclose.

Raymond Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation

Raymond Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Testicular Torsion Clinical Presentation

History

Physical Examination

Intermittent Torsion

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