The spermatic cord provides blood flow to the testicle. When a testicle rotates on this cord, it is referred to as testicular torsion; it causes the flow of blood to stop, causing sudden, often severe pain, and swelling.

Prolonged testicular torsion and loss of blood flow can lead to the death of the testicle and surrounding tissues. Testicular torsion is serious but treatable.

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Severe pain the groin is a sign of a twisted testicle.

Each testicle is attached to the spermatic cord and the scrotum. Testicular torsion happens if the testicle rotates on the cord that runs upward from the testicle into the abdomen.

The rotation twists the spermatic cord and reduces blood flow. If the testicle rotates several times, blood flow can be entirely blocked, causing damage more quickly.

Males who experience testicular torsion may have an inherited trait that allows one or both testicles to rotate freely inside the scrotum. The testicle is only attached to the spermatic cord, and not to the scrotum. This is called a “bell clapper scrotum,” because the testicle “swings” like a bell clapper.

Testicular torsion can happen at any time, while standing, sleeping, exercising, or sitting, and with no apparent trigger in those who are susceptible. Sometimes it is prompted by an injury or because of rapid growth during puberty.

Factors that increase the chance of testicular torsion are:

Age: Testicular torsion is most common in males aged 10-25 years. It can occur at any age, but it is rare over the age of 30 years. About 65 percent of cases occur in adolescents aged 12-18; it affects around 1 in 4,000 males before the age of 25.

Previous testicular torsion: If the torsion occurs once and resolves without treatment, it is likely to happen again in either testicle, unless surgery is performed to correct the underlying problem.

Climate: Torsions are sometimes called “winter syndrome,” because they often happen when the weather is cold. The scrotum of a man who has been lying in a warm bed is relaxed. When he leaves the bed, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.

Testicular torsion in newborns and infants

Sometimes, testicular torsion happens before birth. In this case, the testicle cannot normally be saved, but correctional surgery is recommended after birth to diagnose and correct testicular torsion in the other testicle and to prevent future reproductive problems.

An individual who experiences testicular torsion may have:

  • Sudden or severe pain in one testicle
  • Swelling of the scrotum, the loose bag of skin under the penis that contains the testicles
  • Lumps in the scrotum
  • Nausea
  • Blood in the semen
  • Vomiting
  • Abdominal pain

The man may also notice that one testicle is positioned higher than normal or at an odd angle. The affected testicle may become larger, and it may become red or dark in color.

Symptoms usually appear suddenly, although in some cases, the torsion can develop over a few days.

It is important to seek emergency care for sudden or severe testicle pain. The signs and symptoms may be caused by another condition, but prompt treatment can prevent severe damage or loss of the testicle if it is testicular torsion.

If there is sudden testicle pain that goes away without treatment, it may be that a testicle has twisted and then untwisted without intervention. This is known as intermittent torsion and detorsion.

Even if the testicle untwists on its own, it is important to seek prompt medical help, because surgery may be needed to prevent the problem from happening again.

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The testicles are attached by a cord.

Testicular torsion is normally an emergency. Diagnosis and treatment must be rapid.

The doctor will examine the scrotum, testicles, abdomen, and groin and will ask questions about symptoms to find out whether the problem is testicular torsion or another condition.

The doctor may also test the patient’s reflexes by lightly rubbing or pinching the inside of the thigh on the affected side. This normally causes the testicle to contract. This reflex probably will not occur if there is testicular torsion.

If the diagnosis is uncertain, a urologist will be consulted immediately, to avoid compromising the health of the testicle.

Medical tests that can confirm a diagnosis or to help identify another problem include:

  • Urine or blood tests to check for infection
  • Scrotal ultrasound to assess blood flow – decreased blood flow can be a sign of testicular torsion
  • Nuclear scan of the testicles – this involves injecting tiny amounts of radioactive material into the bloodstream to detect areas of reduced blood flow

Exploratory surgery may be necessary to identify whether symptoms are caused by testicular torsion or another condition. It surgery does not reveal torsion, the surgeon may still attach the testicle to the scrotum wall, to prevent future problems.

If pain has lasted for several hours and the physical exam suggests testicular torsion, surgery may be performed without additional testing, to prevent the loss of the testicle.

Treating testicular torsion

Testicular torsion normally requires emergency surgery. If treated within 4-6 hours, the testicle can usually be saved, but waiting longer can cause permanent damage and may affect the ability to father children.

The surgeon will untwist the spermatic cord to restore blood supply.

Manual detorsion is sometimes possible, but carrying out surgery can prevent a recurrence.

The operation is simple and minimally invasive. It is normally conducted under general anesthesia, and it does not usually require a stay in the hospital.

During surgery, the doctor will:

  • Make a cut in the scrotum
  • Untwist the spermatic cord, if necessary
  • Stitch one or both testicles to the inside of the scrotum, to prevent rotation

Suturing both testicles will prevent torsion from occurring on the other side.

The sooner the testicle is untwisted, the greater the chance of successful treatment. After 6 hours, lasting damage may occur, and after 12 hours, there is a 75 percent chance of losing the testicle.

Once the testicle is dead, it must be removed to prevent gangrenous infection.

After surgery, the patient will need to avoid strenuous activity and sexual activity for several weeks.

Having testicles that can rotate or move back and forth freely in the scrotum is an inherited trait. Some males have this attribute and others do not.

The only way to prevent testicular torsion for a man with this trait is through surgery to attach both testicles to the inside of the scrotum so that they cannot rotate freely.

The majority of cases, if treated within 6 hours, do not require the removal of the testicle (orchiectomy). However, if treatment is delayed for 48 hours, the majority of patients do need to have the affected testicle removed.

Rarely, torsion happens on both sides, but only in around 2 out of every 100. If a testicle is removed, it does not mean that a man cannot have children. The remaining testicle will still produce sufficient sperm to conceive. However, low sperm count has been observed in men who have undergone a torsion.

Additionally, an orchiectomy can alter hormone production in infants.

Sometimes, the remaining testicle will grow larger to compensate. The man should consider wearing protective clothing when doing sports and other activities, to preserve the second testicle.

Written by Christian Nordqvist