Signs of Testicular Torsion
Testicular torsion presents with sudden onset of severe unilateral scrotal pain, often accompanied by nausea and vomiting, a high-riding testicle, and absent cremasteric reflex, requiring immediate surgical intervention. 1, 2
Key Clinical Features
Cardinal Signs
- Sudden onset of severe unilateral scrotal pain (vs. gradual onset in epididymitis) 1, 2
- Red, swollen scrotum 3
- High-riding testicle 1, 2
- Absent cremasteric reflex (though not 100% reliable) 1, 2
- Nausea and vomiting (common associated symptoms) 2, 4
- Hard testis on examination 5
Diagnostic Differentiation from Epididymitis
| Feature | Testicular Torsion | Epididymitis |
|---|---|---|
| Onset | Sudden | Gradual |
| Pain relief with testicular elevation (Prehn sign) | No | Yes |
| Cremasteric reflex | Absent | Present |
| Testicular position | High-riding | Normal |
| Doppler ultrasound | Decreased/absent blood flow | Increased blood flow |
Risk Assessment: TWIST Score
The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score can help assess risk 5:
- Testis swelling (2 points)
- Hard testis (2 points)
- Absent cremasteric reflex (1 point)
- Nausea/vomiting (1 point)
- High-riding testis (1 point)
Score interpretation:
- 0 points: Low risk (negative predictive value 100%)
- 1-5 points: Intermediate risk
- 6+ points: High risk (positive predictive value 93.5%)
Critical Time Considerations
- Testicular torsion is a surgical emergency 2, 4
- Typically a 4-8 hour window exists before permanent ischemic damage occurs 4
- Immediate surgical exploration is indicated when history and physical examination suggest torsion 4
- Delay in treatment may necessitate orchiectomy or lead to decreased fertility 4
Common Pitfalls to Avoid
- Delaying surgical consultation: If torsion is suspected, immediate urology consultation should not be delayed, as outcomes are time-sensitive 2
- Over-reliance on imaging: Ultrasound can be used for diagnosis, but a normal ultrasound cannot definitively exclude torsion 2
- Misdiagnosis as epididymitis: The most common differential diagnosis that leads to delayed treatment 3
- Waiting for imaging when clinical suspicion is high: Immediate surgical exploration is indicated and should not be postponed for imaging studies when history and physical exam strongly suggest torsion 4
- Ignoring torsion in adults: While most common in adolescents, torsion can occur at any age 2
Emergency Management
- Manual detorsion can be attempted in the emergency department while awaiting transfer or consultation 2
- Definitive treatment requires surgical exploration and detorsion 2, 4
Remember that testicular torsion must be excluded in all patients presenting with acute scrotal pain, as early recognition and treatment are essential for testicular salvage 4.