A 20-year-old healthy man arrives at the emergency department at 4 a.m. complaining of one hour of excruciating right testicular pain that radiates to his right lower quadrant and right flank. He’s been vomiting repeatedly. He has had no preceding lower urinary tract symptoms. Vitals are normal except for a heart rate of 115. His right testicle appears swollen with a horizontal high-riding lie and is exquisitely tender to palpation. The cremasteric reflex is absent on the right side.

This is a relatively straightforward case for the diagnosis of testicular torsion, but unfortunately most cases of testicular torsion are not so clear-cut; the classic symptoms and signs often are not present. That is why 30 percent of the cases with failed testicular salvage can be attributed to misdiagnosis, with another 13 percent to delays in treatment after the diagnosis has been made.¹

1. Time counts, but salvageability is possible more than 48 hours after symptom onset.

Testicular torsion is a surgical emergency regardless of the time of onset. The spermatic cord twists, leading to impaired blood flow to the testicle, which causes ischemia and tissue necrosis. The degree of twisting and duration of symptoms are prognostic factors of testis salvage, with 96 percent success rates when perfusion is restored within four hours. Salvage is less than 10 percent if interventions are delayed for more than 24 hours.^2,3 Nonetheless, salvageability has been shown beyond 48 hours after symptom onset, contrary to the historical teaching that symptoms of more than 24 hours are inconsistent with salvageable tissue. In delayed cases that are salvageable, there may be intermittent, rather than continuous, twisting of the spermatic cord, allowing reperfusion of the testicle. Therefore, it is incumbent on emergency physicians to manage all acute scrotum cases as surgical emergencies, even if the time from onset to presentation exceeds 24 hours.

2. Testicular torsion can occur at any age.

Testicular torsion has a bimodal distribution: first year of life and in adolescence. I’ve had urologists tell me emphatically that testicular torsion does not occur in patients older than 40 years of age. Nonetheless, in a study of 469 closed malpractice claims with indemnity payment, the mean age was 23 years and there were four patients over the age of 40.⁴ The literature is rife with case reports of older patients with surgically confirmed testicular torsion.^5–8

3. Testicular torsion can present with minimal, intermittent, or no scrotal pain.

While a sudden onset of severe, unrelenting unilateral scrotal pain radiating to the abdomen and/or flank is typical, the pain of testicular torsion can also be minimal or intermittent—again, attributed to intermittent twisting and untwisting of the spermatic cord that occurs in some cases.⁹ These “pain honeymoons” may partially account for poor clinical outcomes. As many as 20 percent of patients with testicular torsion present with isolated lower abdominal pain.¹⁰ In light of this, all male patients presenting with lower abdominal pain should have a genital examination for signs of torsion.