Approach

Testicular torsion should be diagnosed clinically. A high index of suspicion is important to ensure timely diagnosis and management. Training of primary care and accident and emergency department staff should include early recognition, atypical or warning presentations, urgent referral pathways, and the importance of timely surgery.[12][21]​​

A history and physical examination consistent with testicular torsion mandates an immediate surgical consultation for scrotal exploration, without delay for additional diagnostic tests.[12][21]​​​[22]​​​​​ If diagnosis is unclear, immediate referral is required; however, additional diagnostic tests may help avoid unnecessary surgery.[12][20]

History

Testicular torsion can affect males at any age but boys aged between 12 and 18 years are usually at greatest risk.[3][19][20] Neonates are at risk for extra-vaginal torsion during the perinatal period although this is a rare event.

There is usually a history of sudden-onset severe scrotal pain, often with associated nausea and vomiting.[22]​ There is typically no relief of pain upon elevation of the scrotum. A history of intermittent or acute on-and-off pain may indicate periods of torsion and spontaneous de-torsion. Fever, dysuria, and penile discharge are not typically associated with torsion and would be more suggestive of an infectious or inflammatory process. Trauma is believed to account for only 4% to 10% of cases of torsion.[5][14]

Any patient with a history of undescended testes who presents with sudden abdominal pain should always be evaluated for possible torsion.[3] Urinary frequency is not usually associated with testicular torsion and may suggest alternative diagnoses such as epididymitis or orchitis.

Patients presenting with a symptom duration of <4 to 6 hours have a greater likelihood of testicular viability. Testicular salvage rates decline as the duration of symptoms increases, with greatly reduced testicular salvage at 24 hours and consistently poor results beyond 48 hours.[20][23]

Physical examination

General abdominal examination

  • Patients with intra-vaginal testicular torsion have severe testicular pain. Some may also experience abdominal pain.[3] A patient with a history of undescended testes who presents with sudden abdominal pain should be evaluated for possible torsion.[3]

Genital examination

  • There is usually severe tenderness to palpation of the affected testicle. The testis may have a transverse lie and may be in a higher position ('high-riding') than the unaffected testis. A cremasteric reflex, which normally elicits ipsilateral testicular rise when the inner thigh is stroked, may be absent in cases of torsion.[20] A more delayed presentation may reveal a worsening of the scrotal erythema and oedema, and a reactive hydrocele may develop.[20] Elevation of the testis does not result in any pain relief (negative Prehn’s sign) as compared to that seen in acute epididymitis.[24]

Not all patients present with all of these findings. Testicular tenderness alone may exist without other signs suggestive of torsion.

Clinical relief or improvement after manual de-torsion is highly suggestive of the diagnosis of torsion.

Testicular Workup for Ischaemia and Suspected Torsion (TWIST) score

The TWIST score is a clinical risk score that can be used to support the assessment of a child or young person with testicular pain.​ It is a 7-point score generated from five parameters:[25][26]

  • Testicular swelling (2 points)

  • Hard testis (2 points)

  • High-riding testis (1 point)

  • Nausea or vomiting (1 point)

  • Absent cremasteric reflex (1 point)

Patients are categorised into low risk (score 0 to 2), intermediate risk (3 to 4), and high risk (5 to 7). These categories are useful for clinical decision-making as the sensitivity is 98.4% in low-risk patients and the specificity is 97.5% in high-risk patients.[27]

​Emergency scrotal exploration is recommended if the TWIST score ≥5 in a child or young person with <48 hours of pain, unless there is a strong suspicion of an alternative diagnosis that would significantly change management.[21]​​ However, a score ≤4 does not completely exclude testicular torsion.

The TWIST score has also been validated for the diagnosis of testicular torsion in adults.[28]

Investigations

Advances in imaging modalities have improved the ability to identify cases of torsion; however, if history and physical examination suggest testicular torsion, immediate surgical exploration should take precedence over diagnostic tests.[21][22] If the diagnosis is unclear, additional diagnostic tests may help avoid unnecessary surgery.[12]​ However, the primary goal is to determine the need for immediate surgical intervention as soon as possible.​

Ultrasound assessment

Ultrasound assessment can rapidly and accurately determine the presence of testicular torsion or identify other aetiologies for testicular pain.[29][30]​ Although not usually required, it may be indicated in the following scenarios:[21]

  • Pain present for ≥48 hours, or

  • Strong suspicion of an alternative diagnosis that would significantly change management, or

  • Newborns with a suspected antenatal torsion (to exclude alternative diagnoses).

If ultrasound can be performed without delaying treatment, it may be considered to confirm diagnosis of torsion in children and young people with pain for <48 hours.[21]

Grey-scale ultrasound can identify the whirlpool sign (swirling appearance of the spermatic cord), which is specific to partial or complete testicular torsion.[31][32][33]​ However, the whirlpool sign is of limited utility in neonates, and the sensitivity of detection varies with ultrasonographer experience.[34] Colour Doppler and/or power Doppler studies are also needed to establish the presence or absence of blood flow to the testicles.[29][32]​ Power Doppler is more sensitive to low blood flow than regular colour Doppler.[32]​ Spectral analysis can be used in combination with colour and power Doppler ultrasound to determine pulsatile flow, arterial or venous.[32][33]​​​​​​​

Normal or increased intra-testicular blood flow (i.e., hyperaemia) may suggest an inflammatory diagnosis or successful de-torsion.[29]​ However, blood flow does not exclude a diagnosis of testicular torsion because arterial flow may be present in early phases of torsion, or in partial or intermittent torsion. Comparison with the contralateral testicle should be carried out to identify differences in flow.[24][33]​​ Spectral analysis may also be helpful in these cases.[33][Figure caption and citation for the preceding image starts]: Bilateral transverse colour Doppler images in a 12-year-old boy with right-sided scrotal pain of sudden onset, showing no colour flow signals in the right testis, which is enlarged and has heterogeneous echogenicity; reactive hydrocele (h) and thickening of the scrotal wall (*) are also seen; testicular torsion and bell clapper deformity were confirmed at surgeryAso C, et al. RadioGraphics. 2005;25:1197-1214. Used with permission [Citation ends].com.bmj.content.model.Caption@7580dfde

Urinalysis

If urinalysis is abnormal this usually suggests an alternate diagnosis (e.g., epididymitis or orchitis). However, it is important to note that the urinalysis may be negative in cases of epididymitis or orchitis and positive in the setting of testicular torsion.[35]

Scintigraphy

Further testing to rule out testicular torsion can be done with scintigraphy (nuclear scanning), which has almost 100% sensitivity for identifying patients with torsion; however, it takes longer and is less readily available than Doppler ultrasound.[5][36]​ Scintigraphy provides information about anatomy and vascular perfusion that can be used to distinguish testicular torsion from other non-surgical causes of an acute scrotum, preventing unnecessary surgery. 

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