When a testicle (testis) twists around in the scrotum, the condition is called testicular torsion. An emergency operation is usually needed to treat this condition.
In some young men the tissues that surround the testicle (testis) in the scrotum are lax. Therefore, the testes can move around in the scrotum more than usual. This can be called a 'bell-clapper' deformity. If a testis twists around, the spermatic cord has to twist around too as it is fixed higher up. If this happens, the blood flow to the testis is blocked in the twisted spermatic cord. This is found to happen in around 1 in 4,000 young men.
By OpenStax College, CC BY 3.0, via Wikimedia Commons
Torsion of the testis most commonly occurs in teenage boys aged 13-18 years. Newborn babies and younger children sometimes develop this problem. It is uncommon over the age of 25 but does occur sometimes in older adults and can occur at any age.
A testis with its blood supply cut off is likely to become damaged and die unless the blood flow is quickly restored.
Symptoms of testicular torsion
The typical symptom of torsion of the testicle (testis) is severe pain that develops quickly - within a few hours, often much more quickly. The pain might be in the lower abdomen (tummy). This is because the testis and the tummy share a nerve supply. Any boy or young man with abdominal pain should have their testes checked.
Testicular torsion pain often starts during sport or physical exertion. Alternatively symptoms start in the night and the pain wakes you from sleep. Nausea and vomiting often also occur.
Note: easing pain is not necessarily a good sign because pain also eases as the testis starts to die.
Occasionally, the symptoms are milder.
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What else might it be?
There is a condition called torsion of the epididymal appendage - see image above. This is where an additional part of the epididymis twists, instead of the whole testis. It usually happens in younger boys aged between 7 and 12 years. The pain is in a specific (upper) part of the testis.
Sometimes, in lighter-skinned boys, you might see a small tender lump with bluish discolouration on the upper part of the testis.
Infective conditions such as epididymo-orchitis can be caused by infected urine or sexually transmitted infection such as gonorrhoea (in an older age group).
If there is some doubt about diagnosis, a particular type of ultrasound that looks at blood flow through the scrotum, may be used.
Treatment of testicular torsion
Twisting (torsion) of the testicle (testis) is an emergency. If the blood supply to your testis is cut off for more than about six hours then permanent damage is likely to occur. An emergency operation is usually done. A small cut is made in the skin of your scrotum to expose the testis. The affected testis and spermatic cord are untwisted. The testis is then stitched to the surrounding tissue and fixed in position to prevent torsion happening again. The other testis is also fixed at the same time, as it has a higher-than-average chance of twisting in the future.
The sooner the operation is done, the better the outlook to save your testis. Ideally, the operation should be done within 6-8 hours of symptoms starting. Sometimes the affected testis is removed if the operation is done too late and the testis has died.
Although the operation is usually done as an emergency, it is a fairly small operation which does not take very long.
Occasionally, the twisted testis can be untwisted by a doctor, without needing an operation. However, this procedure can be painful and often not successful. An operation is usually still needed afterwards to fix the testis in place.
If you are worried about your appearance after you have had a testis removed, it may be possible for a surgeon to put a false testis into the scrotum.
Partial torsion and warning pains
Some boys and men have warning pains in a testicle (testis) every now and then, before a full-blown twisting (torsion). These occur suddenly, last for a few minutes, then ease just as suddenly. These pains occur if a testis twists a little and then returns back to its normal place on its own.
An operation to fix the testes in place is usually advised if these warning pains occur. This is because it is likely that at some point a testis will twist fully and emergency surgery will be needed. A planned operation to fix the testes is preferable to waiting for a full-blown torsion to occur.
Both how badly the testis has twisted and how long it stays twisted for are important in the outcome. If correcting surgery happens within six hours of torsion, 9 or 10 out of 10 testes will be saved on average. If surgery is delayed until 12-24 hours then only one testis is saved out of 10.
If a testis cannot be saved and has to be removed, then an implant can be inserted later to restore the appearance of the scrotum to normal.
Research suggests that early treatment is most likely to preserve the ability to father children. Longer delays to treatment and removal of a testis may reduce that ability.
Further reading and references
EAU Paediatric Urology Guidelines. Edn. presented at the EAU Annual Congress Copenhagen; European Association of Urology, 2018
Vasconcelos-Castro S, Soares-Oliveira M; Abdominal pain in teenagers: Beware of testicular torsion. J Pediatr Surg. 2020 Sep55(9):1933-1935. doi: 10.1016/j.jpedsurg.2019.08.014. Epub 2019 Aug 29.
Pomajzl AJ, Leslie SW; Appendix Testes Torsion