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Testicular Torsion
Sara M. O'Hara, MD, FAAP
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Synonyms

              • Torsion, late or "missed" torsion, acute scrotum
            • Definitions

              • Spontaneous or traumatic twisting of testis & spermatic cord within scrotum → vascular occlusion/infarction
              • Testicle twists medially in 2/3 of cases, so manual detorsion laterally is more likely to be effective
                • Direction of manual detorsion is described as "opening book"

            IMAGING

            • General Features

              • Ultrasonographic Findings

                • Nuclear Medicine Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • General Features

                        • Staging, Grading, & Classification

                          • Gross Pathologic & Surgical Features

                            • Microscopic Features

                              CLINICAL ISSUES

                              • Presentation

                                • Demographics

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Image Interpretation Pearls

                                          Selected References

                                          1. Kylat RI: Perinatal testicular torsion. Arch Pediatr. 28(1):75-9, 2021
                                          2. Visalli C et al: Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV). Emerg Radiol. 28(1):209-14, 2021
                                          3. Dupond-Athénor A et al: A multicenter review of undescended testis torsion: a plea for early management. J Pediatr Urol. 17(2):191.e1-6., 2020
                                          4. Elifranji M et al: Segmental testicular infarction associated to torsion: first case report in childhood. Urology. 149:227-9, 2020
                                          5. Gopal M et al: Emergency scrotal exploration in children: is it time for a change in mindset in the UK? J Pediatr Urol. 17(2):190.e1-7, 2020
                                          6. O'Kelly F et al: Delaying urgent exploration in neonatal testicular torsion may have significant consequences for the contralateral testis: a critical literature review. Urology. 153:277-84, 2020
                                          7. Taghavi K et al: The bell-clapper deformity of the testis: the definitive pathological anatomy. J Pediatr Surg. 56(8):1405-10, 2020
                                          8. Vasconcelos-Castro S et al: Manual detorsion in testicular torsion: 5 years of experience at a single center. J Pediatr Surg. 55(12):2728-31, 2020
                                          9. Zhong H et al: Pediatric trauma-induced testicular torsion: a surgical emergency. Urol Int. 1-4, 2020
                                          10. Zvizdic Z et al: Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: a case-control study. Am J Emerg Med. 41:197-200, 2020
                                          11. Carvalho FF et al: Intravaginal torsion of undescended testes. BMJ Case Rep. 12(11), 2019
                                          12. Expert Panel on Urological Imaging et al: ACR Appropriateness Criteria® acute onset of scrotal pain-without trauma, without antecedent mass. J Am Coll Radiol. 16(5S):S38-43, 2019
                                          13. Friedman N et al: Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion. J Pediatr Urol. 15(6):608.e1-6, 2019
                                          14. Sweet DE et al: Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. Abdom Radiol (NY). 45(7):2063-81, 2019
                                          15. Vasconcelos-Castro S et al: Abdominal pain in teenagers: beware of testicular torsion. J Pediatr Surg. 55(9):1933-5, 2019
                                          16. Wang M et al: Testicular torsion postorchiopexy: a case of twisted hammock. Urology. 125:202-4, 2019
                                          17. Zee RS et al: Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion. J Pediatr Urol. 15(5):473-9, 2019
                                          18. Davies SJ et al: Idiopathic scrotal fat necrosis: an unusual cause of scrotal pain. BMJ Case Rep. 2018, 2018
                                          19. Alkhori NA et al: Pediatric scrotal ultrasound: review and update. Pediatr Radiol. 47(9):1125-33, 2017
                                          20. Fenton LZ et al: Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know. Pediatr Radiol. 46(7):1049-58, 2016
                                          21. Friedman AA et al: Standardized education and parental awareness are lacking for testicular torsion. J Pediatr Urol. S1477-5131(16)00021-8. 2016
                                          22. Gielchinsky I et al: Pregnancy rates after testicular torsion. J Urol. S0022-5347(16)30285-3, 2016
                                          23. Sauvestre F et al: Prenatal testicular torsion: not always in the late third trimester. Urology. 89:132-3, 2016
                                          24. Sheth KR et al: Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score. J Urol. 195(6):1870-6 2016
                                          25. Wongwaisayawan S et al: Magnetic resonance of pelvic and gastrointestinal emergencies. Magn Reson Imaging Clin N Am. 24(2):419-31, 2016
                                          26. Riccabona M et al: ESPR Uroradiology Taskforce--imaging recommendations in paediatric uroradiology, part VIII: retrograde urethrography, imaging disorder of sexual development and imaging childhood testicular torsion. Pediatr Radiol. 45(13):2023-8, 2015
                                          27. Esposito F et al: The "whirlpool sign", a US finding in partial torsion of the spermatic cord: 4 cases. J Ultrasound. 17(4):313-5, 2014
                                          28. Dajusta DG et al: Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol. 9(6 Pt A):723-30, 2012
                                          29. Cost NG et al: Pediatric testicular torsion: demographics of national orchiopexy versus orchiectomy rates. J Urol. 185(6 Suppl):2459-63, 2011
                                          30. Molokwu CN et al: Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients. BJU Int. 107(6):990-3, 2011
                                          31. Moore CP et al: Cryptorchid testicular torsion. Pediatr Emerg Care. 27(2):121-3, 2011
                                          32. Chmelnik M et al: Testicular torsion: sonomorphological appearance as a predictor for testicular viability and outcome in neonates and children. Pediatr Surg Int. 26(3):281-6, 2010
                                          33. Waldert M et al: Color Doppler sonography reliably identifies testicular torsion in boys. Urology. 75(5):1170-4, 2010
                                          34. Yagil Y et al: Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 29(1):11-21, 2010
                                          35. Baldisserotto M: Scrotal emergencies. Pediatr Radiol. 39(5):516-21, 2009
                                          36. Fukuda S et al: Idiopathic testicular infarction in a boy initially suspected to have acute epididymo-orchitis associated with mycoplasma infection and Henoch-Schönlein purpura. J Pediatr Urol. 5(1):68-71, 2009
                                          37. Ciftci AO et al: Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 14(5):333-8, 2004
                                          38. Dogra V et al: Acute painful scrotum. Radiol Clin North Am. 42(2):349-63, 2004
                                          39. Kalfa N et al: Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy. J Urol. 172(4 Pt 2):1692-5; discussion 1695, 2004
                                          40. Matsumoto A et al: Torsion of the hernia sac within a hydrocele of the scrotum in a child. Int J Urol. 11(9):789-91, 2004
                                          41. Sorensen MD et al: Prenatal bilateral extravaginal testicular torsion--a case presentation. Pediatr Surg Int. 20(11-12):892-3, 2004
                                          42. Candocia FJ et al: An infant with testicular torsion in the inguinal canal. Pediatr Radiol. 33(10):722-4, 2003
                                          43. Diamond DA et al: Neonatal scrotal haematoma: mimicker of neonatal testicular torsion. BJU Int. 91(7):675-7, 2003
                                          44. Dogra V: Bell-clapper deformity. AJR Am J Roentgenol. 180(4):1176; author reply 1176-7, 2003
                                          45. Dogra VS et al: Sonography of the scrotum. Radiology. 227(1):18-36, 2003
                                          46. Kamaledeen S et al: Intermittent testicular pain: fix the testes. BJU Int. 91(4):406-8, 2003
                                          47. Nelson CP et al: The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg. 38(8):1248-9, 2003
                                          48. Sessions AE et al: Testicular torsion: direction, degree, duration and disinformation. J Urol. 169(2):663-5, 2003
                                          49. Stehr M et al: Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children. Eur J Pediatr Surg. 13(6):386-92, 2003
                                          50. Traubici J et al: Original report. Testicular torsion in neonates and infants: sonographic features in 30 patients. AJR Am J Roentgenol. 180(4):1143-5, 2003
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Top Differential Diagnoses

                                                • Pathology

                                                  • Clinical Issues

                                                    TERMINOLOGY

                                                    • Synonyms

                                                      • Torsion, late or "missed" torsion, acute scrotum
                                                    • Definitions

                                                      • Spontaneous or traumatic twisting of testis & spermatic cord within scrotum → vascular occlusion/infarction
                                                      • Testicle twists medially in 2/3 of cases, so manual detorsion laterally is more likely to be effective
                                                        • Direction of manual detorsion is described as "opening book"

                                                    IMAGING

                                                    • General Features

                                                      • Ultrasonographic Findings

                                                        • Nuclear Medicine Findings

                                                          • Imaging Recommendations

                                                            DIFFERENTIAL DIAGNOSIS

                                                              PATHOLOGY

                                                              • General Features

                                                                • Staging, Grading, & Classification

                                                                  • Gross Pathologic & Surgical Features

                                                                    • Microscopic Features

                                                                      CLINICAL ISSUES

                                                                      • Presentation

                                                                        • Demographics

                                                                          • Natural History & Prognosis

                                                                            • Treatment

                                                                              DIAGNOSTIC CHECKLIST

                                                                              • Consider

                                                                                • Image Interpretation Pearls

                                                                                  Selected References

                                                                                  1. Kylat RI: Perinatal testicular torsion. Arch Pediatr. 28(1):75-9, 2021
                                                                                  2. Visalli C et al: Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV). Emerg Radiol. 28(1):209-14, 2021
                                                                                  3. Dupond-Athénor A et al: A multicenter review of undescended testis torsion: a plea for early management. J Pediatr Urol. 17(2):191.e1-6., 2020
                                                                                  4. Elifranji M et al: Segmental testicular infarction associated to torsion: first case report in childhood. Urology. 149:227-9, 2020
                                                                                  5. Gopal M et al: Emergency scrotal exploration in children: is it time for a change in mindset in the UK? J Pediatr Urol. 17(2):190.e1-7, 2020
                                                                                  6. O'Kelly F et al: Delaying urgent exploration in neonatal testicular torsion may have significant consequences for the contralateral testis: a critical literature review. Urology. 153:277-84, 2020
                                                                                  7. Taghavi K et al: The bell-clapper deformity of the testis: the definitive pathological anatomy. J Pediatr Surg. 56(8):1405-10, 2020
                                                                                  8. Vasconcelos-Castro S et al: Manual detorsion in testicular torsion: 5 years of experience at a single center. J Pediatr Surg. 55(12):2728-31, 2020
                                                                                  9. Zhong H et al: Pediatric trauma-induced testicular torsion: a surgical emergency. Urol Int. 1-4, 2020
                                                                                  10. Zvizdic Z et al: Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: a case-control study. Am J Emerg Med. 41:197-200, 2020
                                                                                  11. Carvalho FF et al: Intravaginal torsion of undescended testes. BMJ Case Rep. 12(11), 2019
                                                                                  12. Expert Panel on Urological Imaging et al: ACR Appropriateness Criteria® acute onset of scrotal pain-without trauma, without antecedent mass. J Am Coll Radiol. 16(5S):S38-43, 2019
                                                                                  13. Friedman N et al: Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion. J Pediatr Urol. 15(6):608.e1-6, 2019
                                                                                  14. Sweet DE et al: Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. Abdom Radiol (NY). 45(7):2063-81, 2019
                                                                                  15. Vasconcelos-Castro S et al: Abdominal pain in teenagers: beware of testicular torsion. J Pediatr Surg. 55(9):1933-5, 2019
                                                                                  16. Wang M et al: Testicular torsion postorchiopexy: a case of twisted hammock. Urology. 125:202-4, 2019
                                                                                  17. Zee RS et al: Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion. J Pediatr Urol. 15(5):473-9, 2019
                                                                                  18. Davies SJ et al: Idiopathic scrotal fat necrosis: an unusual cause of scrotal pain. BMJ Case Rep. 2018, 2018
                                                                                  19. Alkhori NA et al: Pediatric scrotal ultrasound: review and update. Pediatr Radiol. 47(9):1125-33, 2017
                                                                                  20. Fenton LZ et al: Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know. Pediatr Radiol. 46(7):1049-58, 2016
                                                                                  21. Friedman AA et al: Standardized education and parental awareness are lacking for testicular torsion. J Pediatr Urol. S1477-5131(16)00021-8. 2016
                                                                                  22. Gielchinsky I et al: Pregnancy rates after testicular torsion. J Urol. S0022-5347(16)30285-3, 2016
                                                                                  23. Sauvestre F et al: Prenatal testicular torsion: not always in the late third trimester. Urology. 89:132-3, 2016
                                                                                  24. Sheth KR et al: Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score. J Urol. 195(6):1870-6 2016
                                                                                  25. Wongwaisayawan S et al: Magnetic resonance of pelvic and gastrointestinal emergencies. Magn Reson Imaging Clin N Am. 24(2):419-31, 2016
                                                                                  26. Riccabona M et al: ESPR Uroradiology Taskforce--imaging recommendations in paediatric uroradiology, part VIII: retrograde urethrography, imaging disorder of sexual development and imaging childhood testicular torsion. Pediatr Radiol. 45(13):2023-8, 2015
                                                                                  27. Esposito F et al: The "whirlpool sign", a US finding in partial torsion of the spermatic cord: 4 cases. J Ultrasound. 17(4):313-5, 2014
                                                                                  28. Dajusta DG et al: Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol. 9(6 Pt A):723-30, 2012
                                                                                  29. Cost NG et al: Pediatric testicular torsion: demographics of national orchiopexy versus orchiectomy rates. J Urol. 185(6 Suppl):2459-63, 2011
                                                                                  30. Molokwu CN et al: Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients. BJU Int. 107(6):990-3, 2011
                                                                                  31. Moore CP et al: Cryptorchid testicular torsion. Pediatr Emerg Care. 27(2):121-3, 2011
                                                                                  32. Chmelnik M et al: Testicular torsion: sonomorphological appearance as a predictor for testicular viability and outcome in neonates and children. Pediatr Surg Int. 26(3):281-6, 2010
                                                                                  33. Waldert M et al: Color Doppler sonography reliably identifies testicular torsion in boys. Urology. 75(5):1170-4, 2010
                                                                                  34. Yagil Y et al: Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 29(1):11-21, 2010
                                                                                  35. Baldisserotto M: Scrotal emergencies. Pediatr Radiol. 39(5):516-21, 2009
                                                                                  36. Fukuda S et al: Idiopathic testicular infarction in a boy initially suspected to have acute epididymo-orchitis associated with mycoplasma infection and Henoch-Schönlein purpura. J Pediatr Urol. 5(1):68-71, 2009
                                                                                  37. Ciftci AO et al: Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 14(5):333-8, 2004
                                                                                  38. Dogra V et al: Acute painful scrotum. Radiol Clin North Am. 42(2):349-63, 2004
                                                                                  39. Kalfa N et al: Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy. J Urol. 172(4 Pt 2):1692-5; discussion 1695, 2004
                                                                                  40. Matsumoto A et al: Torsion of the hernia sac within a hydrocele of the scrotum in a child. Int J Urol. 11(9):789-91, 2004
                                                                                  41. Sorensen MD et al: Prenatal bilateral extravaginal testicular torsion--a case presentation. Pediatr Surg Int. 20(11-12):892-3, 2004
                                                                                  42. Candocia FJ et al: An infant with testicular torsion in the inguinal canal. Pediatr Radiol. 33(10):722-4, 2003
                                                                                  43. Diamond DA et al: Neonatal scrotal haematoma: mimicker of neonatal testicular torsion. BJU Int. 91(7):675-7, 2003
                                                                                  44. Dogra V: Bell-clapper deformity. AJR Am J Roentgenol. 180(4):1176; author reply 1176-7, 2003
                                                                                  45. Dogra VS et al: Sonography of the scrotum. Radiology. 227(1):18-36, 2003
                                                                                  46. Kamaledeen S et al: Intermittent testicular pain: fix the testes. BJU Int. 91(4):406-8, 2003
                                                                                  47. Nelson CP et al: The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg. 38(8):1248-9, 2003
                                                                                  48. Sessions AE et al: Testicular torsion: direction, degree, duration and disinformation. J Urol. 169(2):663-5, 2003
                                                                                  49. Stehr M et al: Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children. Eur J Pediatr Surg. 13(6):386-92, 2003
                                                                                  50. Traubici J et al: Original report. Testicular torsion in neonates and infants: sonographic features in 30 patients. AJR Am J Roentgenol. 180(4):1143-5, 2003