What is intermittent torsion?

Intermittent Testicular Torsion

Intermittent testicular torsion (ITT) is a condition characterized by recurrent episodes of acute scrotal pain with rapid onset and spontaneous resolution, caused by temporary twisting of the spermatic cord that resolves on its own, but which portends a significant risk for future complete testicular torsion and infarction if left untreated. 1

Clinical Presentation

• Key Characteristics:

  • Recurrent episodes of severe scrotal pain with rapid onset and spontaneous resolution
  • Mean of 4.3 painful episodes before diagnosis (range 1-30) 1
  • Mean age at presentation is 12.2 years (range 4-17) 1
  • Nausea and/or vomiting occurs in approximately 25% of patients 1
  • Pain typically resolves completely between episodes

• Physical Examination Findings:

  • Horizontal lie of the testis is highly correlated with bell-clapper deformity 1, 2
  • Bell-clapper deformity (abnormal attachment of the testis allowing excessive mobility) is found in nearly 100% of cases at surgical exploration 3
  • Normal testicular appearance between pain episodes
  • Left testis is more commonly affected (53.3%) than right (37.8%), with bilateral involvement in 8.9% of cases 2

Diagnostic Challenges

• ITT cannot be ruled out by MRI during asymptomatic periods 4
• Diagnosis is often missed or delayed, with patients frequently receiving alternative diagnoses
• Patients with ITT are at significantly increased risk of developing complete testicular torsion requiring emergency surgery 3
• The condition is often underreported and underdiagnosed 2

Anatomical Basis

• Horizontal lie of the testis is the most common anatomical anomaly causing ITT (49% of cases) 2
• Bell-clapper deformity (incomplete attachment of the tunica vaginalis) is the second most common cause (27.5% of cases) 2
• These anatomical variations allow abnormal testicular mobility, predisposing to torsion

Management

• Definitive Treatment:

  • Bilateral orchidopexy (testicular fixation) is the standard of care 1, 3, 2
  • Surgery should be performed electively once the diagnosis is suspected 3
  • Procedure involves fixation of both testes to prevent future torsion events
  • Bilateral fixation is recommended as contralateral bell-clapper deformity is present in 88-90% of cases 3

• Outcomes:

  • Surgical fixation results in complete resolution of symptoms in 97% of patients 1
  • Elective surgery has a 100% testicular preservation rate compared to only 47% preservation when emergency surgery is required for complete torsion 3
  • Low surgical morbidity 1

Important Considerations

• ITT should be considered in any patient with recurrent acute scrotal pain that resolves spontaneously
• Misdiagnosis or delayed diagnosis significantly increases the risk of complete torsion and testicular loss
• Non-absorbable sutures may be preferred for fixation, as recurrent torsion has been reported even years after fixation with absorbable sutures 5
• The condition should be differentiated from epididymo-orchitis, which typically has a more gradual onset and positive Prehn sign (pain relief with testicular elevation) 6

Clinical Implications

• Prompt recognition and surgical referral are essential to prevent progression to complete torsion
• Patients with suspected ITT should be referred for urological evaluation even if asymptomatic at presentation
• Bilateral orchidopexy is both therapeutic (resolving pain) and preventive (avoiding future complete torsion)
• Failure to diagnose ITT may result in testicular loss if complete torsion occurs

Early recognition and surgical intervention for ITT is critical to prevent the potentially devastating outcome of testicular infarction and loss.