Overview Snapshot A 14-year-old boy is brought to the emergency room for an acute onset of testicular pain. The sharp pain started 2 hours ago on the right side of his scrotum. He also reports nausea and vomiting associated with the pain. Physical exam reveals the right scrotum to be erythematous and swollen. The cremasteric reflex is absent. He is immediately rushed into surgery for detorsion. Introduction Clinical definition twisting of spermatic cord that results in compromised blood flow and ischemia this is considered a surgical emergency Epidemiology demographics neonatal adolescent years Pathogenesis processus vaginalis (path as testes leaves abdomen with peritoneal lining) twists, causing decreased or absent blood flow to testis and epididymis Risk factors Cryptorchidism Accounts for ~10% of cases of testicular torsion Increases risk of torsion by 10-fold compared to non-cryptorchid testes Presentation Symptoms primary symptoms in adolescents acute onset and severe pain in unilateral scrotum nausea vomiting in neonates blue and firm unilateral scrotal mass Physical exam inspection erythema and swelling tenderness to palpation absent cremasteric reflex (L1-2 nerve root) Imaging Doppler ultrasound indications if testicular torsion is suspected but not confirmed with physical exam and history findings decreased or absent blood flow Differential Epididymitis positive cremasteric reflex Treatment Operative orchiopexy (bilateral) indications within 24 hours of disease onset 4-8 hour window before there is permanent damage from ischemia bilateral orchiopexy should be performed as contralateral testis is also at risk for future torsion outcomes 90-100% with viable testes if within 6 hours 50% if within 12 hours < 10% if after 24 hours Complications Testicular ischemia Infertility or subfertility