Testicular torsion is twisting of the spermatic cord, in which the blood vessels are squeezed and blood flow to the testicle stops. Without a timely operation the tissue dies irreversibly – this is one of the true emergencies in urology.
It most often affects boys and teenagers between ten and eighteen years old, but it can happen at any age and is among the leading causes of losing a testicle in young men.
The most important point: with sudden severe pain in a testicle, you do not book an appointment. Go straight to the nearest emergency department or call 112 (the European emergency number). Dr Penev sees patients in Plovdiv and Karlovo after such an episode – for a check after surgery or for recurring pain.
What testicular torsion is
In some boys the covering of the testicle is attached higher than usual, and the testicle can rotate freely around the spermatic cord like the clapper of a bell. A sudden contraction of the muscle that lifts it – in the cold, during sport or in sleep – turns it around its axis and squeezes the artery and veins.
The chance of saving the testicle is highest when blood flow is restored within about six hours of the start of the pain, and it falls sharply after twelve hours.
Symptoms
- sudden, very severe pain in one testicle, often starting during sleep or physical exertion;
- rapid swelling and redness of one half of the scrotum;
- the testicle sits higher than usual, sometimes lying horizontally;
- nausea and vomiting, especially in children;
- pain in the abdomen or groin – in young children sometimes the only symptom.
A temperature and burning on passing urine are usually absent. Short episodes of severe pain that pass on their own within minutes are known as intermittent torsion and need a planned examination before complete twisting occurs.
All of the symptoms listed are an emergency – do not wait for the pain to pass, but go straight to an emergency department or call 112.
Causes and risk factors
The main cause is the congenital feature of the coverings described above, which is usually present on both sides. Triggers include sudden exertion, a sports injury, cold and the rapid growth of the testicles during puberty. The risk is higher in a testicle that has not fully descended into the scrotum – see the article on undescended testicle (cryptorchidism).
Diagnosis
The diagnosis is above all clinical – the sudden onset, the position of the testicle and the absence of a particular reflex when the thigh is touched (the cremasteric reflex) are enough for an experienced urologist to decide on surgery. A urine test rules out infection.
Doppler ultrasound shows reduced or absent blood flow and a twisted spermatic cord, but when the picture is convincing it must not delay the operation. Dr Penev uses ultrasound of the scrotum for the planned assessment of boys and men with recurring pain and to tell torsion apart from the other causes of a lump or swelling in the testicle. When in doubt, a urologist prefers to operate rather than wait.
Treatment
The only treatment is an emergency operation. Through a small incision the testicle is untwisted and the surgeon assesses whether the tissue is still viable. A testicle that has been saved is fixed to the wall of the scrotum so that it cannot twist again; the other testicle is fixed as well. A testicle that has died is removed, and a prosthesis can be fitted later.
This kind of emergency operation is done in hospital – in Plovdiv, Dr Penev is part of the team at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela), where planned scrotal operations are also performed. Recovery takes a few days of rest and two to four weeks without sport or heavy exertion.
When to see a urologist
Emergency department or 112 – for any sudden severe pain in a testicle, especially with swelling and nausea, whatever your age.
A planned appointment with Dr Penev – for episodes of pain that have passed on their own, for a difference in the size of the testicles after an episode, and for a follow-up ultrasound after surgery. Children and teenagers are seen as part of paediatric urology, with a parent present.
Prevention
Torsion cannot be predicted, but losing the testicle can be avoided by acting quickly. Talk to the boys in your family and explain that pain in a testicle is nothing to be embarrassed about and must be reported at once. When intermittent torsion has been confirmed, preventive fixation of both testicles greatly reduces the risk of complete twisting.
With torsion, hours make the difference – with sudden severe pain in a testicle, seek emergency help immediately. For a planned consultation after an episode or a check after surgery, book an appointment with Dr Penev.
Frequently asked questions
Can torsion happen in an adult man?
Yes, although less often. Teenagers are most affected, but torsion has also been described in men over thirty and even over forty, so sudden severe pain in a testicle is an emergency at any age.
Can the testicle untwist on its own?
In what is called intermittent torsion, the pain sometimes suddenly settles within minutes. This is not a reason to relax but a reason for a planned examination with ultrasound, because the next episode may not pass and the testicle could be lost.
What happens to fertility after losing one testicle?
The healthy testicle usually takes over, and most men keep normal fertility and normal testosterone levels. If you wish, a semen analysis can be done in adulthood, and for cosmetic reasons a prosthesis can be fitted.
Why is the healthy testicle also fixed during the operation?
The anatomical feature that allows the twisting is most often present on both sides. Fixing the other testicle during the same operation protects it from twisting in the future.
Is it torsion if the pain starts after a knock during sport?
It can be – an injury sometimes triggers torsion, and the symptoms overlap. Pain that does not ease within an hour of the knock, or that gets worse, must be assessed urgently by a doctor.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.