What are the signs and symptoms of torsion?

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Signs and Symptoms of Testicular Torsion

Testicular torsion presents with sudden severe pain, swelling, high-riding testicle, and negative Prehn's sign, with decreased or absent blood flow on ultrasound. 1

Clinical Presentation

Cardinal Signs and Symptoms

  • Sudden onset of severe unilateral scrotal pain
  • Nausea and vomiting (common accompanying symptoms)
  • Scrotal swelling and erythema
  • High-riding testicle (due to shortening of the spermatic cord)
  • Absent cremasteric reflex (most accurate clinical sign)
  • Negative Prehn's sign (pain not relieved by elevation of the scrotum)
  • Horizontal lie of the testicle (abnormal orientation)

Ultrasound Findings

  • Decreased or absent blood flow on color Doppler imaging
  • "Whirlpool sign" - spiral twist of the spermatic cord (most specific sign)
  • Enlarged, heterogeneous testis that may appear hypoechoic
  • Ipsilateral hydrocele and scrotal wall thickening
  • Pseudomass below the point of torsion (congested epididymis and vessels) 2

Differential Diagnosis Features

Epididymitis

  • More gradual onset of pain (vs. sudden in torsion)
  • Positive Prehn's sign (pain relief with scrotal elevation)
  • Often associated with urinary symptoms
  • Increased blood flow to the epididymis on ultrasound
  • Enlarged and hypoechoic epididymis due to edema 2, 1

Torsion of Testicular Appendage

  • Most common in prepubertal boys
  • "Blue dot sign" may be visible through the scrotal skin
  • Less severe pain than testicular torsion
  • Normal testicular blood flow on ultrasound 1

Time-Critical Considerations

The critical time window for optimal testicular salvage is less than 6-8 hours from symptom onset. After this period, irreparable damage may occur due to ischemia, significantly reducing salvage rates. 1, 3

Diagnostic Accuracy

  • Color Doppler ultrasound sensitivity: 69-96.8%
  • Color Doppler ultrasound specificity: 87-100%
  • "Whirlpool sign" on ultrasound: 96% sensitivity, 99% specificity 2, 1

Common Pitfalls

  1. Misdiagnosing torsion as epididymitis (most common diagnostic error)
  2. Relying solely on the presence of cremasteric reflex to rule out torsion
  3. Delaying surgical consultation when torsion is clinically suspected
  4. Failing to recognize intermittent torsion in children with recurrent pain
  5. Overlooking the possibility of torsion in patients with normal urinalysis 1

Management Considerations

If testicular torsion is suspected based on clinical presentation, immediate urological consultation is warranted without waiting for imaging studies. Manual detorsion can be attempted while awaiting surgical intervention, but restoration of blood flow must be confirmed afterward. 1, 4

Remember that testicular torsion is primarily a clinical diagnosis, and when strongly suspected, surgical exploration should not be delayed for imaging studies if this would postpone definitive treatment beyond the critical 6-hour window. 3

References

1
Guideline

Acute Abdominal and Scrotal Pain Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Testicular torsion.

American family physician, 2006

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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