Testicular torsion occurs when the spermatic cord twists within the tunica vaginalis, resulting in ischemia to the epididymis and the testis. Testicular torsion may occur in the absence of a preceding event or after minor trauma. Patients typically experience acute severe pain that may be accompanied by nausea and vomiting.
On physical examination, the affected testis is edematous, tender to palpation, erythematous, and slightly elevated. The testis is also frequently found to be lying horizontally, displacing the epididymis so that it’s not found in the normal posterolateral position. The unilateral absence of the cremasteric reflex is the most sensitive physical examination finding in testicular torsion.
Doppler ultrasound may be helpful in the diagnosis when there are equivocal clinical findings, but should not delay treatment. Immediate surgical intervention can salvage an ischemic testis if performed within six hours, but the success rate decreases significantly beyond 12 hours. Manual detorsion may also be performed in a similar manner to opening a book, in a medial to lateral motion.