Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the testicle. When this happens, it causes the flow of blood to the testis to stop causing sudden, often severe pain, and swelling. It should be treated as a serious emergency as delayed intervention commonly leads to death of the affected testis.

Torsion is not a common problem. It happens in about 1 in 4,000 males under the age of 25. Testicular torsion is most common between ages 12 and 18 years but can also happen at any age, even in newborns and in older men.

In most males, a testicle can’t twist because the tissue around it is well attached. Some males are born with no tissue holding the testes to the scrotum (The scrotum is the skin sac that holds the testicles). This lets the testes "swing” inside the scrotum.

Torsion can happen on either side, but rarely on both sides. Physical activity doesn’t cause torsion. It may happen during exercise, sitting, standing or even sleeping.

The most common sign of testicular torsion is sudden, severe pain on one side of the scrotum. If one side quickly becomes larger than the other, change in scrotum color especially redness or darkening, can also be a sign. One may also feel nauseous and experience episodes of vomiting.

Testicular torsion is always an emergency. Diagnosis and treatment should be done immediately.

The doctor will examine the scrotum, testicles, abdomen, and groin and will ask questions about symptoms to find out whether the problem is testicular torsion or another condition with similar symptoms.

Once the diagnosis of testicular torsion isn’t clear, some medical tests can be performed. A scrotal ultrasound scan to assess for any decreased blood flow to the concerned testis, urine or blood tests to check for any infection as the cause, and some medical centers a nuclear scans of the testes to detect areas of reduced blood flow.

If pain has lasted for several hours and the physical exam suggests testicular torsion, surgery may be performed without additional testing, to prevent the loss of the testicle. If surgery does not reveal torsion, the surgeon may still attach the testicle to the scrotum wall, to prevent future problems.

After the diagnosis of testicular torsion, surgery to restore the blood supply needs to be done. Lasting damage starts after 6 hours of torsion. Studies show that nearly 3 in 4 patients need the testicle removed if surgery is delayed past 12 hours.

All patients with torsion will need surgery, ideally by a urologist specialist, if available. It is possible to untwist the chord in the emergency room, but surgery is still needed. At surgery, if the testis is found to be good, the surgeon will untwist the testicle and sew stitches to prevent future torsion. If the testis is found to be already dead, it will have to be removed. Surgery to the unaffected testis will also be done to attach it more firmly to the scrotum and prevent the same condition from affecting it in the future.

Reassurance is needed after the surgery, especially if one testis has been found dead and removed. One working testicle is needed for normal fertility and male features. A single testicle can make normal amounts of sperm and testosterone, although some studies show that up to one third of patients have a lower sperm count after a torsion. One may also have a decrease in the amount of testosterone in their blood at an early age. It’s a good idea to have one’s testosterone levels checked regularly as they get older.

It is important to know that having testicles that can rotate in the scrotum is a trait inherited by some males. If one has this trait, usually with positive family history of torsion, physical exam and imaging findings suggestive, the only way to prevent testicular torsion is surgery to attach both testicles to the inside of the scrotum.

The writer is Resident in Surgery,

Rwanda Military Hospital,

iangashugi@gmail.com