An 18-year-old man presents with acute, severe testicular pain, abdominal pain, and vomiting. On examination, his testis is too tender to touch. He tells you that he had a brief episode of testicular pain three weeks ago, but it resolved spontaneously after about 30 minutes.
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This man is most likely to have suffered testicular torsion. Testicular torsion is a surgical emergency that occurs when the spermatic cord twists, resulting in ischaemia. It can happen in any age group but is most commonly seen in 12-18-year-olds.
The typical presentation is with an acutely painful, swollen testis and abdominal pain. This is often accompanied by nausea and vomiting. There is sometimes a preceding history of minor testicular trauma or of prior episodes of testicular pain caused by torsion that has untwisted itself.
Examination signs that may be present include:
- Testis lies high in the scrotum
- Testis too tender to touch
- Opposite testis lies horizontally (Angell’s sign)
- Pain not relieved by elevating testis (Negative Prehn’s sign)
- Absence of cremasteric reflex
2. What are the main risk factors for developing this diagnosis?
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Risk factors for the development of testicular torsion include:
- Increased testicular size
- Testicular tumour
- Congenital abnormality of processus vaginalis (‘bell-clapper deformity’)
- Trauma
- Previous history of torsion
- Family history of torsion
3. Why does this patient have abdominal pain?
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The abdominal pain seen in testicular torsion occurs because the testis retains its embryological nerve supply, primarily derived from the T10 sympathetic pathway.
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Testicular torsion requires immediate intervention to restore the flow of blood. If treated within six hours, there is a 90% chance of saving the testicle. At 12 hours, the rate decreases to 50%; at 24 hours, it drops to 10%, and after 24 hours, the ability to save the testicle approaches zero. About 40% of cases result in loss of the testicle.
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