History and exam

Key diagnostic factors

common

testicular pain

Usually a history of sudden-onset scrotal pain, often with nausea and vomiting. Testicular tenderness alone may exist without other signs suggestive of torsion.

intermittent pain

A history of intermittent testicular pain may indicate periods of torsion and spontaneous de-torsion.[3]

no pain relief upon elevation of scrotum

There is usually no relief of pain upon elevation of the scrotum (negative Prehn’s sign).[24]

scrotal swelling or oedema

With time, the scrotum becomes more oedematous.[20]

scrotal erythema

With time erythema may develop.[20]

reactive hydrocele

With time a reactive hydrocele may develop.[20]

high-riding testicle

The affected testicle may appear higher in position than the unaffected testicle.

horizontal lie

On physical examination, there may be tenderness and a horizontal lie of the affected testicle.

absent cremasteric reflex

An absent cremasteric reflex on the affected side is suggestive of torsion.[3]

Other diagnostic factors

common

nausea and vomiting

Common in the paediatric population with testicular torsion.

abdominal pain

May be associated with testicular torsion, particularly in the setting of an undescended testis.[3] Any male child presenting with abdominal pain should always have their testes inspected as part of a complete examination.

uncommon

fever

Fever is rarely associated with torsion.

Risk factors

strong

age under 25 years

Testicular torsion can affect males at any age but usually boys aged between 12 to 18 years are at greater risk of intra-vaginal torsion than other age groups.[3][19][20]

neonate

Neonates are at risk of extra-vaginal torsion during the perinatal period, although this is a rare condition.

bell clapper deformity

The bell clapper deformity, an anatomical anomaly that allows the testicles to rotate freely within the tunica vaginalis, accounts for about 90% of cases of intra-vaginal torsion.[5] In addition, the cremasteric muscle creates a rotational pull around the spermatic cord, particularly with a strong contraction, that can also contribute to the development of testicular torsion.[13]

weak

trauma/exercise

Trauma is believed to account for only 4% to 10% of cases.[5][14] There are cases of trauma-induced testicular torsion; caution is important to avoid delay in diagnosis and treatment in this setting.[13]

intermittent testicular pain

Recurrent episodes of acute unilateral scrotal pain are common in patients with chronic intermittent torsion. Symptoms usually last for a few hours and the examination and diagnostic tests are usually normal by the time the patient presents. The pain usually resolves spontaneously within a few hours. Chronic intermittent torsion may rarely result in segmental ischaemia of the testis.[3]

undescended testicle

Torsion is 10 times more likely in patients with an undescended testicle (cryptorchidism). For example, a 7-month-old with cryptorchidism who developed torsion of the testes in the inguinal canal has been reported. Hence, any patient with a history of an undescended testicle who presents with sudden abdominal pain should be evaluated for possible torsion.[3]

cold weather

Higher incidence rates of torsion have been reported during the colder months: 30% during autumn and 24% during winter compared with 22% in the summer.[3]

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