Can an undescended testis (cryptorchidism) experience torsion?

Can Undescended Testis Have Torsion?

Yes, undescended testes can absolutely undergo torsion, and this represents a frequently missed surgical emergency that accounts for approximately 10% of all testicular torsions in the pediatric population. 1

Clinical Significance and Epidemiology

The risk of torsion in undescended testes is significantly understated in clinical practice. 2 While the AUA guidelines extensively discuss cryptorchidism management, they specifically identify torsion as one of the main reasons for treatment of cryptorchidism, alongside infertility risk, testicular malignancy, and associated inguinal hernia. 3

• Torsion of undescended testis accounts for 9.7% of all testicular torsions in children 1
• The median age at presentation is approximately 2-2.3 years, which is younger than typical scrotal testicular torsion 4
• This can occur even before the currently recommended age for orchiopexy (6 months corrected gestational age) 2

Critical Diagnostic Challenges

Classic Presentation

The hallmark clinical presentation is a painful inguinal mass with an empty ipsilateral hemiscrotum, seen in 92% of cases. 4 Specific features include:

• Groin lump (91% of cases) with or without pain 1
• Acute groin pain (97% of cases) 4
• Vomiting (27% of cases) 4
• The testis may be located in the abdomen, inguinal canal, superficial inguinal pouch, or upper scrotum 3

Common Misdiagnoses

The diagnosis is frequently missed or delayed because clinicians mistake it for:

• Incarcerated inguinal hernia (36% of cases) 1
• Inguinal testicular torsion (46% of cases) 1
• Epididymitis (9% of cases) 1

Major Pitfall: Ultrasound Limitations

Ultrasound Doppler has poor diagnostic accuracy for torsion of undescended testis and should NOT delay surgical exploration. 5 This is a critical distinction from scrotal testicular torsion:

• Ultrasound led to correct diagnosis in only 55-59% of cases 1, 4
• Ultrasound findings were misinterpreted as incarcerated inguinal hernia in multiple cases 1, 5
• In one series, ultrasound incorrectly diagnosed torsion when incarcerated hernia was actually present, and vice versa 5
• Torsion of undescended testis should be a clinical rather than radiologic diagnosis 5

Management Algorithm

Immediate Action Required

Any boy with known undescended testis presenting with acute groin pain or tender groin mass requires immediate surgical exploration, even without confirmatory imaging. 2, 4

1. Clinical diagnosis takes precedence: A tender groin mass with empty ipsilateral scrotum in a boy with known cryptorchidism = surgical emergency 4
2. Do not wait for imaging: Ultrasound may be performed if immediately available but must not delay surgery 1, 5
3. Urgent surgical consultation: Time to surgery is the critical determinant of testicular salvage 4

Time-Dependent Outcomes

The salvage rate is dramatically time-dependent:

• Referral <6 hours: 85% salvage rate among conservatively treated testes 4
• Referral >6 hours: 37% salvage rate among conservatively treated testes 4
• Overall testis preservation rate is only 18% due to delayed presentation 1
• Early management could have prevented 68% of testis loss 4

Special Populations at Risk

Boys with neurological disorders appear at higher risk, with 18% of cases occurring in this population. 4 This may be due to communication difficulties delaying diagnosis.

Key Clinical Recommendations

For any boy with an empty scrotum presenting with acute abdomen or red and tender swelling in the groin, torsion of undescended testis must be in the differential diagnosis. 2 The main reason for poor outcomes is absence of surgical consultation in a timely manner (73% of cases). 4

• Palpate testes for quality and position at each well-child visit to document baseline testicular location 3
• Educate families of boys with known cryptorchidism about this risk 2
• Maintain high clinical suspicion even in the absence of severe pain 1
• Proceed directly to surgical exploration based on clinical findings alone 5