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# Testicular torsion

Testicular torsion is a twist of the [spermatic cord](https://durgical.com/en/anatomy/spermatic-cord/) that cuts off blood to the testis; it causes sudden severe pain and the testis can be lost within hours.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Spermatic cord](https://durgical.com/en/anatomy/spermatic-cord/)
- [Testes](https://durgical.com/en/anatomy/testis/)
- [Epididymis](https://durgical.com/en/anatomy/epididymis/)
- [Scrotum](https://durgical.com/en/anatomy/scrotum/)
- [Testicular arteries](https://durgical.com/en/anatomy/testicular-artery-pelvis/)
- [Testicular veins and pampiniform plexus](https://durgical.com/en/anatomy/testicular-vein-pampiniform-plexus/)
- [Ductus deferens](https://durgical.com/en/anatomy/ductus-deferens/)

## In embryology

- [Cryptorchidism](https://durgical.com/en/embryology/cryptorchidism/)

## In the clinical exam

- [Male genital exam: transillumination, cremasteric reflex, Prehn sign](https://durgical.com/en/clinical-exam/male-genital-exam-transillumination-cremasteric-reflex-prehn-sign/)

## Why it happens

- [Hypoxia, ischemia and reperfusion injury](https://durgical.com/en/general-pathology/hypoxia-ischemia-and-reperfusion-injury/)
- [Infarction: red vs white, and what decides the damage](https://durgical.com/en/general-pathology/infarction-red-vs-white-and-what-decides-the-damage/)
- [Testis: seminiferous tubules, Sertoli and Leydig cells, spermatogenesis](https://durgical.com/en/histology/testis-seminiferous-tubules-sertoli-and-leydig-cells-spermatogenesis/)

## What it is

Twisting of the spermatic cord that cuts off blood flow to the testis. It is a surgical emergency: the testis can be lost within hours.

## Who gets it

Peaks in adolescence, with a smaller peak in newborns, but can happen at any age. A leading cause of acute scrotal pain in boys and teenagers.

## Causes

- Bell-clapper deformity: a high attachment of the tunica vaginalis lets the testis rotate freely
- Intravaginal torsion in children and adolescents
- Extravaginal torsion in newborns (whole cord and tunica)
- Triggers: sleep, exercise, minor trauma, cold

## Risk factors

- Adolescence
- Bell-clapper deformity (often on both sides)
- Previous self-resolving episodes
- Undescended testis
- Family history

## Pathophysiology

The twisted cord first blocks venous outflow and then arterial inflow, causing congestion, ischaemia and infarction. Salvage depends on time since onset and the degree of twisting; the chance of saving the testis falls steeply after about six hours (a widely cited window).

## Classification

- Intravaginal (most; children and adolescents) or extravaginal (newborns)
- Complete, partial or intermittent torsion

## Symptoms and signs

- Sudden severe pain in one side of the [scrotum](https://durgical.com/en/anatomy/scrotum/), often waking the patient
- Nausea and vomiting
- Swollen, very tender testis, high-riding with a horizontal lie
- Absent cremasteric reflex on the affected side
- Sometimes felt as lower abdominal or groin pain (the scrotum must be examined)

## Red flags

- Any sudden scrotal pain in a boy or young man (torsion until proven otherwise)
- Pain with vomiting
- Absent cremasteric reflex
- Previous short episodes of similar pain (intermittent torsion)

## Diagnosis

**Clinical**
A clinical diagnosis: sudden pain, high-riding horizontal [testis](https://durgical.com/en/anatomy/testis/) and absent cremasteric reflex; scores such as TWIST help stratify. With high suspicion, the patient goes straight to surgery.

**Tests**
Urinalysis is usually normal (helps against epididymitis).

**Imaging**
Colour Doppler ultrasound shows reduced or absent flow and may show a twisted cord (whirlpool sign); it must not delay surgical exploration.

## Differential diagnosis

- Torsion of a testicular appendage («blue dot» sign)
- Epididymitis or epididymo-orchitis
- Incarcerated inguinal hernia
- Trauma or haematoma
- Testicular tumour
- IgA vasculitis (Henoch–Schönlein purpura)

## Goal of treatment

Restore blood flow as fast as possible to save the testis, and prevent recurrence on both sides.

## Treatment

**Surgical**
Emergency scrotal exploration with detorsion; orchidopexy of a viable testis and of the other testis; orchiectomy if the testis is necrotic.

**Acute**
Manual detorsion (usually rotating outwards, «opening the book») can be tried while surgery is arranged; it does not replace exploration.

**Medical**
Analgesics and antiemetics.

## Complications

- Loss of the testis (orchiectomy)
- Testicular atrophy
- Reduced fertility
- Recurrence if the testes are not fixed
- Psychological impact

## Prognosis

Salvage rates are high when surgery happens within the first hours and low after a day. One healthy testis usually keeps normal hormone levels and fertility.

## Test yourself

Think of the answer, then tap the question to see it.

## Which anatomical variant predisposes to testicular torsion?

The bell-clapper deformity: a high tunica vaginalis attachment that lets the testis rotate.

## Which reflex is typically absent in testicular torsion?

The cremasteric reflex on the affected side.

## Should Doppler ultrasound be done before surgery when suspicion is high?

No. Imaging must not delay surgical exploration.

## Why is the other testis also fixed during surgery?

The bell-clapper deformity is often bilateral, so contralateral orchidopexy prevents future torsion.

## What is the time window for saving the testis?

Best within about six hours of pain onset; the salvage rate falls steeply afterwards.

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## Related conditions

- [Epididymitis](https://durgical.com/en/conditions/epididymitis/)
- [Kidney stones (urolithiasis)](https://durgical.com/en/conditions/kidney-stones/)
- [Hydrocele](https://durgical.com/en/conditions/hydrocele/)
- [Testicular cancer](https://durgical.com/en/conditions/testicular-cancer/)
- [Cryptorchidism (undescended testis)](https://durgical.com/en/conditions/cryptorchidism/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Testicular Torsion](https://www.ncbi.nlm.nih.gov/books/NBK448199/) (StatPearls (NCBI Bookshelf), 2023).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/testicular-torsion/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/testicular-torsion/