Men have two testicles that rest inside the scrotum. A cord known as the spermatic cord carries blood to the testicles. When a man experiences torsion of testes (testicular torsion), this cord twists. As a result, blood flow is affected and the tissues in the testicle can start to die.
The cause of the majority of cases is the bell clapper deformity, an anatomic abnormality that is present in some males. This anatomical condition allows the spermatic cord to twist more easily, resulting in compromise of the blood supply to the testicle. This can occur spontaneously or may be associated with trauma. There is no way to detect this deformity. In a significant number of men who have this anatomical abnormality will have it in both testicles.
Each testicle is attached to the spermatic cord and the scrotum. Testicular torsion happens if the testicle rotates on the cord that runs upward from the testicle into the abdomen.
The rotation twists the spermatic cord and reduces blood flow. If the testicle rotates several times, blood flow can be entirely blocked, causing damage more quickly.
Males who experience testicular torsion may have an inherited trait that allows one or both testicles to rotate freely inside the scrotum. The testicle is only attached to the spermatic cord, and not to the scrotum. This is called a “bell clapper scrotum,” because the testicle “swings” like a bell clapper.
Testicular torsion can happen at any time, while standing, sleeping, exercising, or sitting, and with no apparent trigger in those who are susceptible. Sometimes it is prompted by an injury or because of rapid growth during puberty.
Factors that increase the chance of testicular torsion are:
Age: Testicular torsion is most common in males aged 10-25 years. It can occur at any age, but it is rare over the age of 30 years. About 65% of cases occur in adolescents aged 12-18; it affects around 1 in 4,000 males before the age of 25.
Previous testicular torsion: If the torsion occurs once and resolves without treatment, it is likely to happen again in either testicle, unless surgery is performed to correct the underlying problem.
Climate: Torsions are sometimes called “winter syndrome,” because they often happen when the weather is cold. The scrotum of a man who has been lying in a warm bed is relaxed. When he leaves the bed, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.
Testicular torsion in newborns and infants
Sometimes, testicular torsion happens before birth. In this case, the testicle cannot normally be saved, but correctional surgery is recommended after birth to diagnose and correct testicular torsion in the other testicle and to prevent future reproductive problems.
Pain and swelling of the scrotal sac are the main symptoms of testicular torsion. The onset of pain may be quite sudden, and the pain can be severe. Swelling may be limited to just one side, or it can occur in the entire scrotum. You may notice that one testicle is higher than the other. Some men also experience:
- lumps in the scrotal sac
- blood in the semen
There are other potential causes of severe testicular pain, such as epididymitis, but you should still take these symptoms seriously and seek emergency treatment.
The health care provider will examine you. The exam may show:
- You have extreme tenderness and swelling in the testicle area.
- The testicle on the affected side is higher.
You may have a Doppler ultrasound of the testicle to check the blood flow. There will be no blood flowing through the area if you have complete torsion. Blood flow may be reduced if the cord is partly twisted.
Testicular torsion can cause the following complications:
- Damage to or death of the testicle.When testicular torsion is not treated for several hours, blocked blood flow can cause permanent damage to the testicle. If the testicle is badly damaged, it has to be surgically removed.
- Inability to father children.In some cases, damage or loss of a testicle affects a man’s ability to father children.
With prompt diagnosis and treatment the testicle can often be saved. Typically, when a torsion takes place, the surface of the testicle has rotated towards the midline of the body. Non-surgical correction can sometimes be accomplished by manually rotating the testicle in the opposite direction (i.e., outward, towards the thigh); if this is initially unsuccessful, a forced manual rotation in the other direction may correct the problem. The success rate of manual detorsion is not known.
Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood. If treated either manually or surgically within six hours, there is a high chance (approx. 90%) 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 0. About 40% of cases result in loss of the testicle. Common treatment for children is surgically sewing the testicle to the scrotum to prevent future recurrence.