Testicular torsion

Last updated: August 29, 2023

Summarytoggle arrow icon

Testicular torsion is the sudden twisting of the spermatic cord within the scrotum. It most commonly affects neonates and young men. Because of the risk of ischemia and possible infarction of the testis, it is considered a urological emergency. Testicular torsion is characterized by sudden-onset unilateral testicular pain, which may radiate to the lower abdomen, with nausea and vomiting. Clinical findings include a high-riding testis with an absent cremasteric reflex. Imaging with duplex ultrasound of the scrotum may be required if the clinical diagnosis is in doubt. If testicular torsion is suspected, prompt surgical exploration within six hours of symptom onset is essential to salvage the testis. Important differential diagnoses, e.g., orchitis and epididymitis, should be ruled out before initiating treatment.

Epidemiologytoggle arrow icon

  • Peak incidence: neonatal period (first 30 days of life) and during puberty (10–14 years) [1]
  • Prevalence
    • 3.8 per 100,000 male individuals under the age of 18 (two-thirds of cases occur between 12 and 18 years of age) [2]
    • Accounts for 10–15% of acute scrotal illness in children within the United States [3]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Sudden, severe, unilateral scrotal pain in a patient with a tender, abnormally positioned testis on examination should be managed as testicular torsion until proven otherwise.


Initial managementtoggle arrow icon

Management of testicular torsion is time-sensitive.

Do not delay urological referral in order to perform imaging or manual detorsion, especially if clinical suspicion is high, as there is a significant risk of infertility and/or testicular loss if definitive surgical management is delayed > 6 hours from symptom onset.

Clinical decision score [10][11][13]

The TWIST score may be used to help guide decisions on imaging prior to surgical exploration.

  • High-risk patients with a score of ≥ 6: extremely high likelihood of torsion
  • Low-risk patients (especially those with a score of 0): very low risk of torsion (ultrasound may not be required, however, this controversial) [10][11][13]
  • Medium-risk patients or clinical uncertainty: Obtain a scrotal ultrasound to help confirm diagnosis.
Testicular workup for ischemia and suspected torsion score (TWIST score) [10][13]
Clinical feature Score if present
Swelling of the scrotum
  • 2
Testis firm to palpation
  • 2
Cremasteric reflex absent
  • 1
Scrotal elevation (high-riding testis)
  • 1
Nausea or vomiting
  • 1

RIsk categories (from original derivation and validation cohort)

  • Low risk: 0–2
  • Medium risk: 3–4
  • High risk: ≥ 5 [10][11][13]

Diagnosticstoggle arrow icon

Testicular torsion is typically a clinical diagnosis. Do not delay definitive treatment for diagnostic workup if clinical suspicion is high.


Imaging is not routinely indicated in patients in which there is high clinical suspicion but should be considered in patients with atypical clinical features.

Duplex ultrasound of the scrotum [11][14][15][16][17]

Either formal ultrasound or POCUS can be used to diagnose torsion, depending on operator skill and availability. [18]

Other imaging modalities

These are typically time-consuming studies and may not be readily available in emergency situations.

  • Radionuclide imaging [3][19]
    • Indications
    • Characteristic findings
      • Testicular torsion
        • Areas that do not absorb radionuclide as a result of decreased blood flow to the affected testis (“Cold spots”)
        • Asymmetric blood flow
      • Epididymitis: areas where there is increased radionuclide absorption as a result of increased blood flow in inflammation (“Hot spots”)
  • MRI with IV contrast: may be used as an alternative to radionuclide imaging [12]

Surgical intervention is recommended for suspected testicular torsion, regardless of radiological findings.

Laboratory studies

Differential diagnosestoggle arrow icon

Differential diagnosis of scrotal pain [3]
Disorder History Examination Laboratory studies
Testicular torsion
  • Gradual onset (e.g., < 6 weeks if acute, ≥ 6 weeks if chronic) [21]
  • Painful swelling with possible induration
  • Possible history of urethral discharge
  • Fever, dysuria, urinary frequency
Testicular tumor
  • Slow progression (e.g., weeks to months)
  • Usually painless mass (however, the patient may experience a dull ache or describe a “heavy” sensation in the testis)
  • Easy palpation of solid mass
  • Possible manifestations of metastatic disease (e.g., distant lymphadenopathy, chest pain, gastrointestinal symptoms)
  • Possible swelling of the ipsilateral lower limb (venous engorgement due to obstruction)
Torsion of testicular appendage (hydatid of Morgagni)
  • Insidious onset of unilateral scrotal pain
  • Usually seen in boys 7–14 years of age

Torsion of testicular appendage (hydatid of Morgagni) [22]

  • Description: an embryological remnant on the upper pole of the testes or at the epididymis (the remnant of the Mullerian duct) that has the potential to rotate
  • Clinical features: Symptoms resemble acute testicular torsion.
    • Typically seen in boys 7–14 years of age
    • Insidious unilateral scrotal tenderness
    • Blue dot sign (infarction of the hydatid of Morgagni that appears blue through the scrotal skin)
  • Imaging: Doppler ultrasound may show an enlarged testicular appendix and/or mild hydrocele with preserved testicular blood flow.
  • Management
    • A conservative approach with NSAIDs may be considered.
    • If the diagnosis is in doubt, surgical intervention is required to examine the testes.

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Testicular torsion is a medical emergency and should ideally be treated within 6 hours of the onset of symptoms for the best chance of testicular salvage. Manual detorsion in the emergency department may be attempted prior to surgery for immediate pain relief, but should not delay transferring the patient to the operating room.

Manual testicular detorsion [3][12]

  • Indication: : may be attempted prior to surgery for immediate pain relief or if surgery is not immediately available
  • Procedure
    • Consider performing under ultrasound guidance to increase the likelihood of success.
    • Rotate the testis laterally toward the thigh ; two-thirds of torsions occur toward the midline.
    • If lateral rotation does not provide symptom relief, rotate the testis toward the midline; one-third of torsions occur laterally. [23]
    • Surgery should still be performed in all patients to resolve any possible degree of remaining torsion and to prevent recurrence. [14][14]

Because of the risk of infertility, surgical exploration of the scrotum is recommended in any patient suspected of having testicular torsion, even if manual detorsion has been attempted.

Exploratory surgery [3][14]

  • Indication: suspected testicular torsion
  • Timing: ideally, within 6 hours of symptom onset [3]
  • Procedure

Acute management checklisttoggle arrow icon

  • Examine the patient and consider using the TWIST score to help guide further management.
  • High likelihood of torsion: urgent urology referral without prior imaging
  • Intermediate or low risk: Consider imaging (provided it can be performed rapidly) prior to urology consult.
  • Start pain management with parenteral analgesics.
  • If pain persists and surgery is not immediately available, consider manual testicular detorsion.
  • Urgent transfer to the OR for surgical exploration of the scrotal sac

Prognosistoggle arrow icon

  • Testicular salvage rates depend on the interval of time between symptom onset and restoration of testicular blood flow. [3][24][25]
    • Within 6 hours: 90–100% [3]
    • > 12 hours: 20–60%
    • > 24 hours: up to 20%
  • Late or absent surgical intervention → testicular ischemia (with/without necrosis) → disruption of the blood-testis barrier formation of antisperm antibodies infertility [24][25]

Referencestoggle arrow icon

  1. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management.. Am Fam Physician. 2013; 88 (12): p.835-40.
  2. Bombiński P, Warchoł S, Brzewski M, et al. Ultrasonography of Extravaginal Testicular Torsion in Neonates. Polish Journal of Radiology. 2016; 81: p.469-472.doi: 10.12659/pjr.897066 . | Open in Read by QxMD
  3. Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ. Intermittent Testicular Torsion in the Pediatric Patient: Sonographic Indicators of a Difficult Diagnosis. American Journal of Roentgenology. 2013; 201 (4): p.912-918.doi: 10.2214/ajr.12.9448 . | Open in Read by QxMD
  4. Sharp VJ, Arlen AM. Testicular Torsion: Diagnosis, Evaluation, and Management. Am Fam Physician. 2013; 88 (12): p.835-840.
  5. Frohlich LC, Paydar-Darian N, Cilento BG, Lee LK. Prospective Validation of Clinical Score for Males Presenting With an Acute Scrotum. Acad Emerg Med. 2017; 24 (12): p.1474-1482.doi: 10.1111/acem.13295 . | Open in Read by QxMD
  6. Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score.. J Urol. 2016; 195 (6): p.1870-6.doi: 10.1016/j.juro.2016.01.101 . | Open in Read by QxMD
  7. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  8. Barbosa JABA, de Freitas PFS, Carvalho SAD, et al. Validation of the TWIST score for testicular torsion in adults. Int Urol Nephrol. 2020; 53 (1): p.7-11.doi: 10.1007/s11255-020-02618-4 . | Open in Read by QxMD
  9. Huang W-Y, Chen Y-F, Chang H-C, Yang T-K, Hsieh J-T, Huang K-H. The incidence rate and characteristics in patients with testicular torsion: a nationwide, population-based study. Acta Paediatr. 2013; 102 (8): p.e363-e367.doi: 10.1111/apa.12275 . | Open in Read by QxMD
  10. William P. Adelman, MD, and Alain Joffe, MD, MPH. The adolescent with a painful scrotum. Contemporary Pediatrics. 2000.
  11. Ringdahl E,Teague L. Testicular Torsion. Am Fam Physician. 2006; 74 (10): p.1739-1743.
  12. Riaz-ul-haq M, Mahdi DE, Elhassan EU. Neonatal testicular torsion: a review article. Iran J Pediatr. 2012; 22 (3): p.281-289.
  13. Mano R, Livne PM, Nevo A, Sivan B, Ben-meir D. Testicular torsion in the first year of life: characteristics and treatment outcome. Urology. 2013; 82 (5): p.1132-1137.doi: 10.1016/j.urology.2013.07.018 . | Open in Read by QxMD
  14. Ta A et al.. Testicular torsion and the acute scrotum. Eur J Emerg Med. 2016; 23 (3): p.160-165.doi: 10.1097/mej.0000000000000303 . | Open in Read by QxMD
  15. Liguori G et al.. Role of US in acute scrotal pain. World J Urol. 2011; 29 (5): p.639-643.doi: 10.1007/s00345-011-0698-8 . | Open in Read by QxMD
  16. McDowall J et al.. The ultrasonographic “whirlpool sign” in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis. Emerg Radiol. 2018; 25 (3): p.281-292.doi: 10.1007/s10140-018-1579-x . | Open in Read by QxMD
  17. Wang CL, Aryal B, Oto A, et al. ACR Appropriateness Criteria® Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass. Journal of the American College of Radiology. 2019; 16 (5): p.S38-S43.doi: 10.1016/j.jacr.2019.02.016 . | Open in Read by QxMD
  18. Blaivas M, Sierzenski P, Lambert M. Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography. Acad Emerg Med. 2001; 8 (1): p.90-93.doi: 10.1111/j.1553-2712.2001.tb00563.x . | Open in Read by QxMD
  19. Wu H-C et al.. Comparison of Radionuclide Imaging and Ultrasonography in the Differentiation of Acute Testicular Torsion and Inflammatory Testicular Disease. Clin Nucl Med. 2002; 27 (7): p.490-493.doi: 10.1097/00003072-200207000-00005 . | Open in Read by QxMD
  20. Galejs LE. Diagnosis and treatment of the acute scrotum.. Am Fam Physician. 1999; 59 (4): p.817-24.
  21. Epididymitis. Updated: June 4, 2015. Accessed: November 23, 2020.
  22. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. 1998; 102 (1 Pt 1): p.73-76.
  23. Lavallee ME, Cash J. Testicular Torsion. Curr Sports Med Rep. 2005; 4 (2): p.102-104.doi: 10.1097/01.csmr.0000306081.13064.a2 . | Open in Read by QxMD
  24. Jacobsen FM, Rudlang TM, Fode M, et al. The Impact of Testicular Torsion on Testicular Function. The World Journal of Men's Health. 2019; 37.doi: 10.5534/wjmh.190037 . | Open in Read by QxMD
  25. Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int. 2003; 92 (3): p.200-203.doi: 10.1046/j.1464-410x.2003.04307.x . | Open in Read by QxMD
  26. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007; 177 (1): p.297-301.doi: 10.1016/j.juro.2006.08.128 . | Open in Read by QxMD
  27. Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2012; 189 (5): p.1859-1864.doi: 10.1016/j.juro.2012.10.056 . | Open in Read by QxMD

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