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  Consider the diagnosis of testicular torsion in any male with abdominal pain.

  
  
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  Perform a genitourinary (GU) examination on males complaining of abdominal pain, even if they have no GU complaints. This is especially important in adolescent males.

  
  
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  When considering testicular torsion as a diagnosis, never allow an imaging study or laboratory test to delay an emergent urologic consultation.

  
  
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  When attempting manual detorsion, remember the direction to turn the testicle is like opening a book.

Testicular torsion is a primary concern in a male with acute scrotal pain and should be considered in all males with abdominal pain. Torsion is due to twisting of the testicle around the spermatic cord. It initially compromises venous outflow, and later arterial blood flow to the testicle, resulting in ischemia and infarction. The longer the torsion persists, the less chance of testicular survival. Hence, time is of the essence in the diagnosis and management of suspected torsion.

Peak incidence of testicular torsion occurs in the first year of life, before the testes descend into the scrotum, with a second peak at puberty, when the volume of the testes rapidly increases. It occurs in about 1 in 4,000 males a year. Testicular torsion is 10 times more likely to occur in a male with an undescended testis.

The initial effect of torsion is obstruction of venous return. If torsion persists, venous obstruction leads to worsening edema and ultimately to arterial obstruction and ischemia. The amount of venous obstruction is related to the degree of rotation of the testis on the spermatic cord and vascular supply. Incomplete rotation causes a lesser degree of edema and vascular congestion, whereas complete rotation leads to immediate complete obstruction and ischemia. The amount of testicular damage is related to the degree and duration of venous and arterial obstruction. If pain has been present for <6 hours, the testicular salvage rate is 80–100%.

History

Abnormal development of the fixation of the tunica vaginalis to the posterior scrotal wall can cause the testicle to hang freely in the scrotum like the clapper of a bell, aligned in a horizontal rather than vertical axis (Figure 41-1). This predisposes the testicle to torse, frequently in the context of strenuous physical activity or scrotal trauma. Torsion can also occur during sleep, when the cremaster muscle contracts. Other risk factors for testicular torsion include incomplete descent of the testes and testicular atrophy.

Patients will present with acute onset of unilateral scrotal pain. The pain is usually severe and noted in the lower abdomen, the inguinal canal, or the testis. Nausea and vomiting are often associated. Because it is an ischemic vascular event, the pain is not positional initially. Later, with significant testicular and scrotal edema, the pain may become more positional.

Physical Examination

Examination of the opposite testis may be helpful because anatomic abnormalities are often bilateral. Examine the patient in both the supine and standing positions. When the patient is standing, look for the affected testicle to be aligned in a horizontal (bell-clapper deformity) rather than vertical axis (normal). The involved testicle will often lie higher in the scrotum than the opposite side.