Young men (average age 16-17.5 years) complain of the sudden onset of pain in one testicle, followed by swelling of the affected testicle, reddening of the overlying scrotal skin, lower abdominal pain, nausea, and vomiting. An examination reveals a swollen, tender, retracted testicle that often lies in the horizontal plane (bell-clapper deformity). The spermatic cord is frequently swollen on the affected side. In delayed presentations, the entire hemiscrotum may be swollen, tender, and firm. The urine is usually clear with a normal urinalysis. In one-third of cases, there is a peripheral leukocytosis.
Obtain urologic consultation immediately and prepare to go to the operating room without delay. Doppler ultrasound or technetium scanning may be helpful if these procedures will not delay surgery. In the interim, detorsion may be attempted if the patient is seen within a few hours of onset: open the affected testicle like a book, that is, the right testicle turned counterclockwise when viewed from below and the left testicle turned clockwise. Pain relief is immediate. Decreased pain prompts additional turns (as many as three) to complete detorsion; increased pain prompts detorsion in the opposite direction. Do not delay operative intervention for ancillary studies since testicular infarction will occur within 6 to 12 hours after torsion.