Testicular torsion
The clock started when the pain did — explore, don't scan. Sudden severe testicular pain in a boy or young man is torsion until proven otherwise. Call urology immediately for scrotal exploration; ultrasound must not delay theatre. Built for revision, not live patient decisions.
Settle them, and check the basics
time-criticalRed flags — what each should make you think
Always examine the testes in a boy or young man with abdominal pain. Torsion can present as lower abdominal pain and vomiting, and teenagers may be too embarrassed to mention their testicles. Salvage rates fall sharply after about 6 hours.
First actions
- ☎Urology now
- NBMNil by mouth
- 💊Analgesia + antiemetic
- 🚫Don't delay for ultrasound
- 📝Document time of onset
Understand the patient
torsion vs the restTypical features
- Peaks in neonates and adolescents (12–18), but can occur at any age
- Sudden severe pain, often waking from sleep or during exercise
- Testis high, horizontal, very tender; absent cremasteric reflex
- TWIST score can help, but should not delay exploration
Differentials
- Torsion of the appendix testis — younger (7–12), pain at the upper pole, "blue dot" sign; cremasteric reflex present. Still often explored if torsion can't be excluded
- Epididymo-orchitis — gradual onset, dysuria, discharge, fever; STI (under 35) or UTI organisms (older)
- Others — trauma, incarcerated hernia, tumour, mumps orchitis, Henoch–Schönlein purpura
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Sudden severe pain, high horizontal testis, vomiting, absent cremasteric reflex.
Clinical — surgical exploration confirms.
Urgent scrotal exploration: detorsion and bilateral fixation (orchidopexy), or orchidectomy if non-viable.
Perineal/scrotal pain out of proportion, swelling, crepitus, skin necrosis, sepsis; diabetes, obesity.
Clinical; CT if diagnosis unclear (don't delay surgery).
Resuscitation, broad IV antibiotics, emergency surgical debridement.
Irreducible groin lump extending into scrotum, obstruction.
Clinical, imaging.
Surgical review. See the hernias page.
Investigate — what to order, when, and what it tells you
test with a question in mindDoppler USS
Urine
Bloods
How the plan comes together
disposition · handovertheatre
Suspected torsion → scrotal exploration now.
Hand over: time of onset, findings, consent discussed.
home
Confident epididymo-orchitis or appendix testis torsion after senior review: analgesia, antibiotics if infection (STI testing), safety-net and follow-up.
Sudden testicular pain is torsion until a surgeon says otherwise. Don't let an ultrasound or a busy department delay theatre. Nicely done getting here.
Clerking template
copy or downloadTesticular torsion — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 9 knownFrequently asked questions
quick answersWhat are the red flags for testicular torsion?
- Sudden severe testicular pain — think torsion
- High-riding, horizontal testis — think torsion
- Absent cremasteric reflex — think torsion
- Nausea and vomiting with scrotal pain — think torsion
- "Abdominal pain" in a teenage boy — think examine the testes
- Necrotic, crepitant perineum + sepsis — think Fournier's gangrene
What is the initial management of testicular torsion?
- Urology now — for urgent scrotal exploration
- Nil by mouth — prepare for theatre
- Analgesia + antiemetic — —
- Don't delay for ultrasound — clinical suspicion is enough
- Document time of onset — —
Always alongside senior support and your local guideline.
What diagnoses must you not miss in testicular torsion?
- Testicular torsion — explore now
- Fournier's gangrene — necrotising perineal infection
- Incarcerated inguinal hernia — groin lump
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for testicular torsion?
- Doppler USS — Only if it won't delay surgery and the diagnosis is genuinely in doubt. A normal scan doesn't exclude intermittent torsion.
- Urine — For epididymo-orchitis.
- Bloods — FBC, U&E, G&S.
Admit or discharge: how is the plan decided for testicular torsion?
- Theatre — Suspected torsion → scrotal exploration now.
- Home — Confident epididymo-orchitis or appendix testis torsion after senior review: analgesia, antibiotics if infection (STI testing), safety-net and follow-up.
Is there a clerking template for testicular torsion?
Yes — there is a clerking template for testicular torsion on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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