🔵 Testicular Torsion & The Acute Scrotum
A urological emergency where hours determine whether the testis survives — and where the clinical examination alone may be sufficient to go straight to theatre.
Testicular Torsion — Pathology & Surgical Management
The Pathology
Testicular torsion occurs when the testis twists on its spermatic cord. The veins are compressed first — the arteries (higher pressure) continue to deliver blood, causing the testis to become acutely oedematous and engorged. As interstitial pressure rises, arterial inflow is eventually cut off, leading to ischaemia and infarction.
The 6-Hour Window — This Is Non-Negotiable
Irreversible ischaemic necrosis occurs within 6 hours of onset. Surgical exploration must be undertaken immediately. Do not delay for USS when the clinical picture is highly suspicious.
- < 6 hours: Testicular salvage rate ~90–100%
- 6–12 hours: Salvage rate drops to ~50%
- > 24 hours: Salvage rate <10% — orchidectomy almost inevitable
Why Does Torsion Happen? The “Bell-Clapper” Deformity
The underlying anatomical defect responsible for most intravaginal torsions in adolescents is the bell-clapper deformity:
- The tunica vaginalis abnormally invests high up on the spermatic cord, completely surrounding both the testis and epididymis
- This eliminates the posterior scrotal wall attachment — the testis hangs freely and can spin within the tunica, like a clapper inside a bell
- Any sudden movement (exercise, nocturnal cremasteric contraction) can trigger the twist
The Deformity Is Bilateral — The Contralateral Testis Must Be Fixed
The bell-clapper deformity is almost universally bilateral. A prophylactic orchidopexy of the contralateral, healthy testis must always be performed at the same operation. Failure to do so exposes the patient to torsion on the remaining side — potentially bilateral testicular loss.
Emergency Scrotal Exploration — The Operative Steps
Performed under general anaesthesia via a midline scrotal raphe incision (or two separate transverse scrotal incisions if bilateral fixation is planned from the outset). The steps are precise and must be followed in order.
Scrotal Incision & Delivery of the Testis
A midline scrotal raphe incision is made through skin, dartos muscle, and scrotal fascia to expose the tunica vaginalis. The tunica is opened to deliver the testis out of the wound.
Identification & Manual De-torsion
The direction and degree of torsion are noted. Torsion most commonly occurs medially (the testis rotates inward). The testis is untwisted manually — typically rotated laterally (like opening a book outward). The number of twists is documented in the operative note.
Warm Saline Wrap — “Wait and Watch”
Once de-torsed, the testis is wrapped in warm saline-soaked swabs for 10–15 minutes to allow reperfusion. The colour, turgor, and capillary return are assessed. A viable testis will pink up; a non-viable testis remains dark, mottled, and flaccid.
If Viable — Orchidopexy (3-Point Fixation)
The testis is fixed to the posterior scrotal wall using 3 non-absorbable sutures (e.g. 3/0 Prolene or Ethibond) at the lower pole, upper pole, and lateral aspect of the tunica albuginea. This 3-point fixation permanently recreates the anchoring the bell-clapper deformity had eliminated. A dartos pouch technique may alternatively be used — the testis is tucked into a pocket fashioned between the dartos muscle and skin, providing fixation without sutures through the tunica itself.
If Non-Viable — Orchidectomy
If the testis shows no recovery after the warm wrap — remains dark, necrotic, and flaccid, with no arterial bleeding on tunica albuginea incision — an orchidectomy is performed. The spermatic cord is ligated and divided at the level of the internal inguinal ring. A testicular prosthesis (silicone implant) can be offered simultaneously or as a staged procedure for cosmetic and psychological benefit.
Contralateral Orchidopexy — Always, Without Exception
Regardless of what was found on the affected side, the contralateral testis is explored and fixed through a separate scrotal incision using identical 3-point fixation. This step is never omitted. The contralateral testis has the same bell-clapper anatomy and is at equal future risk of torsion.
Wound Closure
The scrotal wall is closed in layers — dartos with an absorbable suture (e.g. 2/0 Vicryl), skin with absorbable sutures or clips. A supportive scrotal dressing is applied. The patient is typically discharged the same day or the following morning.
Intraoperative Viability Assessment — When the Answer Isn’t Clear
The decision to save or sacrifice the testis is not always straightforward. These adjuncts guide the surgeon when the warm wrap is inconclusive:
Manual De-torsion in the ED — A Temporising Measure Only
Some centres attempt manual de-torsion in the emergency department to buy time and restore blood flow before theatre. The classic technique rotates the testis laterally (outward) — “opening a book.” Relief of pain and return of a normal testicular lie suggest success. However, this is a temporising measure only. It does not replace surgical exploration and bilateral orchidopexy. Even if apparently successful, the patient must still go to theatre — an incompletely de-torsed testis (e.g. 360° of twist with only 180° corrected) will remain ischaemic without the surgeon’s confirmation.
The “Blue Dot” Sign
A distinct and examinable condition, easily confused with true testicular torsion. Understanding it prevents unnecessary bilateral scrotal exploration.
Age as a Diagnostic Clue
Testicular torsion most commonly strikes boys aged 10–16. The hydatid of Morgagni twists just before puberty. Epididymo-orchitis in this age group is rare — in any adolescent with an acute scrotum, torsion must be actively excluded before any other diagnosis is entertained.