Testicular Torsion Clinical Presentation

Updated: Aug 17, 2022
  • Author: Ranjiv I Mathews, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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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 torsio Example of scrotal appearance in testicular torsion.

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.