What are the consequences if testicular torsion is not operated on or removed?

Consequences of Untreated Testicular Torsion

If testicular torsion is not surgically corrected, permanent testicular loss occurs due to irreversible ischemic damage, typically within 6-8 hours of symptom onset, resulting in either testicular necrosis requiring orchiectomy or a non-functional atrophied testicle. 1, 2, 3

Time-Dependent Tissue Damage

The critical window for testicular salvage is extremely narrow:

• Permanent ischemic damage begins after 6-8 hours of torsion, with testicular viability progressively declining beyond this point 1, 2
• Surgical outcomes are significantly better when intervention occurs within 12 hours of symptom onset, but salvage rates drop precipitously after the initial 6-8 hour window 1
• The pathophysiology involves initial venous obstruction (due to thinner vessel walls and lower pressure), followed by arterial occlusion, ultimately leading to complete testicular ischemia 1

Immediate Consequences Without Surgery

Testicular Necrosis and Loss

• The orchiectomy rate is 42% in boys undergoing surgery for testicular torsion, reflecting cases where diagnosis or treatment was delayed 3
• Complete torsion (>450 degrees) results in absent arterial and venous flow, causing rapid tissue death 1
• Even if the testicle is not removed, untreated torsion results in a non-functional, atrophied organ 4

Systemic Complications

• Patients experience severe, unrelenting acute unilateral scrotal pain with nausea and vomiting 3
• The affected testicle becomes enlarged, heterogeneous, and hypoechoic on imaging, with associated scrotal wall thickening and hydrocele 1

Long-Term Consequences

Fertility Implications

• Delay in treatment is associated with decreased fertility, even when the testicle is salvaged 3
• Loss of one testicle reduces overall sperm production and testosterone production capacity
• Studies reporting ipsilateral atrophy rates after delayed treatment range from 9.1% to 47.5% 5

Risk to Contralateral Testicle

• The presence of a "bell-clapper" deformity (found in 82% of patients with intermittent testicular torsion) means the contralateral testicle is also at risk 1
• Without bilateral orchiopexy during surgical correction, the opposite testicle remains vulnerable to future torsion 2, 5

Critical Clinical Context

Testicular torsion accounts for 10-15% of acute scrotal disease in children and affects 3.8 per 100,000 males younger than 18 years annually 3. The condition has a bimodal distribution, with peaks in neonates and postpubertal boys 1, 2.

Why Immediate Surgery Cannot Be Delayed

• If history and physical examination suggest torsion, immediate surgical exploration is indicated and should not be postponed to perform imaging studies 3
• The four- to eight-hour window before permanent damage is absolute—observation is not an option 3, 6
• Unlike other acute conditions, the acute scrotum from torsion cannot simply be observed, as fertility preservation depends on immediate detorsion and orchiopexy 6

Common Pitfall to Avoid

Do not wait for imaging confirmation when clinical suspicion is high. Any patient in whom testicular torsion is strongly considered should undergo immediate exploratory surgery without diagnostic studies 6. The risk of unnecessary surgery is far outweighed by the certainty of testicular loss with delayed treatment.