Testicular torsion
Sudden testicular pain in a boy is torsion until proven otherwise. Call surgery or urology now: the testis can die within 6 hours.
A 14-year-old boy woke at 4 a.m. with severe pain in the left side of his scrotum and lower abdomen. He has vomited twice. The left testis sits higher than the right and is very tender. No dysuria.
Ultrasound first, or theatre?
- Think torsion firstSudden scrotal pain in a boy or young man, especially with vomiting.
- Examine the scrotum in every boy with abdominal painEmbarrassed boys often say "my stomach hurts".
- Call surgery or urology nowTime to theatre decides whether the testis survives.
- Pain relief, nil by mouth, consentGet ready for theatre while waiting.
- Ultrasound only if it won't delayA normal scan does not exclude torsion.
- Both sides fixed in theatreThe other testis is at risk too.
- Any suspected torsion
- Pain onset under 24 hours with a high-riding or horizontal testis
- Absent cremasteric reflex with tenderness
- Newborn with a hard, discoloured scrotum
- Torsion presenting as abdominal pain
- Torsion with spontaneous untwisting (intermittent pain)
- Incarcerated inguinal hernia
- Testicular tumour with bleed
- Appendicitis
| Treatment window | Best salvage if untwisted within 6 hours of pain onset, falls sharply after that |
| Peak ages | Newborns and around puberty (12–18 years), but any age |
| TWIST 5–7 | High risk: theatre without waiting for ultrasound |
| TWIST 3–4 | Intermediate: urgent ultrasound if no delay, otherwise explore |
| TWIST 0–2 | Low risk: torsion less likely, still examine again |
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On this page
How it presents
- Sudden, severe pain in one testis, sometimes waking from sleep, often after exercise or minor trauma.
- Nausea and vomiting are common. Pain can be felt in the lower abdomen or groin.
- Examination: swollen, very tender testis, lying high or horizontal (bell-clapper), absent cremasteric reflex on that side.
The TWIST score
| Finding | Points |
|---|---|
| Testis swelling | 2 |
| Hard testis | 2 |
| Absent cremasteric reflex | 1 |
| Nausea or vomiting | 1 |
| High-riding testis | 1 |
- Other causes more likely
- Still examine again and safety-net
- Urgent Doppler ultrasound if it won't delay
- Surgeon decides
- Straight to theatre
- Do not wait for ultrasound
Torsion or something else?
| Condition | Clues |
|---|---|
| Testicular torsion | Sudden, severe, vomiting, high-riding testis, absent cremasteric reflex |
| Torsion of the appendix testis | Pain more gradual, tender lump at the upper pole, sometimes a "blue dot"; testis itself less tender |
| Epididymo-orchitis | Gradual over days, dysuria, discharge, fever, older or sexually active; cremasteric reflex present |
| Inguinal hernia | Swelling extends from the groin; can't get above it |
| Mumps orchitis | Parotid swelling a few days before |
Epididymo-orchitis is uncommon in young boys without a urinary tract abnormality. If you write "epididymitis" in a teenager with sudden pain, be sure torsion has been excluded by a surgeon.
Management
- Senior surgeon or urologist nowState the time of pain onset.
- Nil by mouth, IV access, analgesiaMorphine or paracetamol IV. Consent for exploration and possible orchidectomy.
- Manual detorsion only by the senior if theatre is delayedRotate outward, "open the book". It does not replace surgery.
- Scrotal explorationUntwist, assess colour and bleeding. Fix if viable; remove if dead.
- Fix the other sideBilateral fixation is standard.
Frequently asked questions
What are the symptoms of testicular torsion?
Sudden, severe pain in one testis or the lower abdomen, often with nausea and vomiting, a swollen, tender, high-riding testis and an absent cremasteric reflex.
What is the time window for testicular torsion?
Best salvage is within 6 hours of pain onset. The chance of saving the testis falls after that, but exploration is still done urgently.
How do you tell testicular torsion from epididymitis?
Torsion starts suddenly with vomiting and an absent cremasteric reflex, usually in boys and adolescents. Epididymitis builds up over days with urinary symptoms and fever, usually in sexually active men. If unsure, the surgeon explores.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 14-year-old boy has sudden left testicular pain and vomiting. His TWIST score is 6 and pain began 3 hours ago. What is the next step?
Answer: Scrotal exploration now. A high TWIST score means likely torsion: theatre now.
- Urine culture: Not first.
- Doppler ultrasound first: Delays treatment in a high-risk case.
- Antibiotics for epididymitis: Wrong diagnosis.
- Analgesia and review in the morning: Testis may die.
2. A 13-year-old boy has abdominal pain and vomiting. His abdomen is soft and non-tender. What has been forgotten?
Answer: Examination of the testes. Testicular torsion often presents as abdominal pain in boys.
- Urine dipstick only: Not enough.
- Ultrasound of the appendix: Examine first.
- Stool test: No.
- Chest X-ray: Not the issue.
3. At exploration, the left testis is twisted and saved. What should be done with the right testis?
Answer: Fix it as well. The bell-clapper anomaly is usually bilateral; fix both testes.
- Remove it: No.
- Ultrasound in 6 months: Fixation is standard now.
- Leave it alone: The anomaly is usually bilateral.
- Biopsy it: No.
4. A 25-year-old sexually active man has 3 days of gradually increasing scrotal pain, swelling, dysuria and fever. Elevating the testis relieves pain. What is the treatment?
Answer: Ceftriaxone + doxycycline. Epididymo-orchitis: young sexually active men → Chlamydia/gonorrhoea → ceftriaxone single dose + doxycycline 10–14 days (treat partners). Older men/UTI-related → enteric organisms → quinolone. Mumps orchitis in unvaccinated. Gradual onset, dysuria, fever, Prehn sign positive (elevation relieves pain). If any doubt about torsion → explore.
- Immediate exploration: Exploration is not needed with a positive Prehn sign and gradual onset.
- Nitrofurantoin: Nitrofurantoin does not cover STIs.
- No treatment: Infection needs treatment.
5. A 10-year-old has scrotal pain for 2 days. The testis lies normally, the cremasteric reflex is present and a small tender blue nodule is seen at the upper pole. What is the management?
Answer: Analgesia and rest. Torsion of the testicular appendage (hydatid of Morgagni) is the commonest cause of acute scrotum in prepubertal boys: gradual pain, localised tenderness at the upper pole, ‘blue dot sign’, cremasteric reflex present. Managed conservatively with analgesia and rest; explore if doubt about testicular torsion. Testicular torsion: sudden severe pain, high-riding horizontal testis, absent cremasteric reflex.
- Immediate exploration: Exploration is not needed when the diagnosis is clear.
- IV antibiotics: This is not infection.
- Orchidectomy: Orchidectomy is not indicated.
6. In the male, what does the gubernaculum become?
Answer: Scrotal ligament. The gubernaculum guides the testis down into the scrotum and remains as the scrotal ligament. In the female, it becomes the ovarian ligament and the round ligament of the uterus. The processus vaginalis becomes the tunica vaginalis.
- Processus vaginalis: A peritoneal outpouching that forms the tunica vaginalis.
- Tunica albuginea: Capsule of the testis.
- Appendix of testis: Remnant of the paramesonephric duct.
- Ductus deferens: From the mesonephric duct.
7. Which cells in the testis produce testosterone, and what controls them?
Answer: Leydig cells, controlled by LH. Leydig (interstitial) cells make testosterone under LH. Sertoli cells, under FSH and testosterone, support spermatogenesis, make androgen-binding protein, inhibin (which feeds back to reduce FSH) and anti-Müllerian hormone, and form the blood–testis barrier.
- Sertoli cells, controlled by FSH: Sertoli cells do not make testosterone.
- Leydig cells, controlled by FSH: FSH acts on Sertoli cells.
- Sertoli cells, controlled by LH: LH acts on Leydig cells.
- Spermatogonia, controlled by inhibin: Spermatogonia are germ cells.
References and dose sources
- EAU guidelines: Paediatric urology (acute scrotum)
- Barbosa et al. TWIST score (J Urol 2013)
- BAUS
- NICE CKS — scrotal pain and swelling
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.