Testicular Torsion

Sometimes, the tissue surrounding a testicle is not well attached to the scrotum. As a result, the testicle may become twisted around the spermatic cord resulting in the blood supply being cut off. The following information should help you better understand this potentially serious health hazard.

What happens under normal conditions?

The testicle (testis) receives its blood supply through the spermatic cord, which arises in the abdomen, courses through the inguinal canal and then enters the scrotum. This cord also includes the vas deferens, which transports sperm to the urethra. While there is more than one source of arterial blood to the testicle, they all enter the testicle via the spermatic cord. Interruption of this arterial route, therefore, will result in a complete cutoff of blood supply and loss of the testicle.

The testicles are organs suspended in a pouch-like skin sac — the scrotum — below the penis. By looking at the scrotum, both the right and left testicle should be approximately equal in size. An asymmetric enlargement, especially if sudden, suggests an underlying pathologic condition on one side. Similarly, the skin color on both sides of the scrotum should be identical. Any change in color, especially redness or darkening, also suggests a problem. Finally, testicles are normally not painful and any pain or discomfort should alert the individual to seek medical attention, even if there is no swelling or skin color change.

What is testicular torsion?

Testicular torsion, or twisting of the testicle resulting in a strangulation of the blood supply, occurs in men whose tissue surrounding the testicle is not well attached to the scrotum. It is important to emphasize that testicular torsion is a MEDICAL EMERGENCY. The testicle will die (infarct) and diminish in size (atrophy) if the blood supply is not restored within approximately six hours. Restoration of the blood supply requires untwisting the cord (de-torsion).

Torsion is relatively rare, occurring in approximately one in 4,000 males under the age of 25.  However, it can also occur in newborns and in older men.

What causes testicular torsion?

In most individuals a testicle cannot twist because the surrounding tissue is well attached to the scrotum.

What are the symptoms of testicular torsion?

The hallmark of testicular torsion is sudden, severe, one-sided testicular pain. Torsion can occur at any time, while sitting or standing, or may awaken an individual from sleep. Physical activity does not cause torsion, but it may occur during sports or physical exercise. There is often associated nausea and vomiting. Slow-onset testicular pain, over several hours or days, can represent torsion, but it is less common. Problems with urination, such as burning or frequency, are not normally associated with torsion. Torsion is not a painless event. The left side tends to be more commonly affected. Torsion in undescended testes is also more common on the left side. In fact, one study reported that 73% of all torsions in undescended testes occurred on the left side. Torsion is usually on one side, with only 2% of the patients developing torsion in both testicles.

Early in the process, there may be no scrotal swelling. However very shortly thereafter, there will be swelling and redness of the scrotal skin. In nearly half of the patients scrotal swelling is found on surgical exploration. Testicles that have died (infarcted), after many hours of torsion, cause the greatest scrotal changes. The scrotum will be very tender, reddened and swollen. Often the individual will not be able to find a comfortable position.

How is testicular torsion diagnosed?

Clinical evaluation by the urologist, consisting of medical history and physical examination, is often sufficient to diagnose torsion. Time is of the essence, so if the urologist cannot exclude torsion or suspects it, surgical intervention must be undertaken without further delay. There are X-ray tests which may be used, especially in those individuals whose examination and history may not be characteristic. Both ultrasound and nuclear medicine techniques can be used to assess blood flow to the testicle, and therefore, can also exclude or confirm torsion. The urinalysis is usually normal and if there is a urinary tract infection, one must also consider the diagnosis of a testicular infection of the testis of epididymis.

How is testicular torsion treated?

Ultimately, all individuals with torsion require surgery. The testicle can at times be manually untwisted in the emergency room, but whether this is successful or not, surgery is necessary. At surgery, the affected testicle will be untwisted and then sutures placed around both testicles to prevent future torsion. Most often this is performed through the scrotum, although an inguinal approach may be used. Unfortunately, there are individuals whose testicles cannot be saved, because it has already infarcted or died. This is determined at surgery. These individuals will undergo removal of the affected testicle at the time of surgery and then placement of sutures around the remaining opposite testicle to prevent future torsion. Irreversible changes and possible damage starts occurring after 6 hours.

What can be expected after treatment for testicular torsion?

Whether the testicle is removed or not, scrotal exploration results in minimal and short-lived discomfort. Oral pain medication may be necessary for a few days. Most surgeons will allow the patient to return to work or school within a few days to a week. However, strenuous physical activity or exercise might be best avoided for several weeks. The sutures that are placed around the testicles are not perceived by the patient and are not bothersome. It would be very rare for torsion to recur after the placement of fixation sutures. Patients and families should be wary of any testicular pain or swelling, however, especially if there is only one remaining testicle. In that case they should seek medical attention immediately.

If the torted testicle is left in place, it still might diminish in size slightly, since there may have been some permanent damage during the hours that the testicle was twisted. It is not possible to predict in whom this will happen, except that testicles torted for the longest time, in general, may have more size reduction. In addition, if one testicle is removed, the opposite testicle may increase in size to greater than normal, which is known as compensatory hypertrophy. Torsion of the testicle cannot be prevented by changes in activity or by taking medication. Only fixation sutures placed around the testis at surgery will prevent future torsion.