A testicular torsion is a twist of the spermatic cord resulting in strangulation of the blood supply to the testis and epididymis. It
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may be (a) intravaginal where the testis twists within the tunica vaginalis, the more common type; or (b) extravaginal, the type that occurs in the neonatal or prenatal period.
Testicular torsion occurs most frequently between the ages of 10 and 30, with a peak at the age of 13 to 15 years, but any age group may be affected. The left side is said to be affected more often, and 2% are said to present with torsion of both testes.
The presentation is usually one of sudden onset of severe pain in the hemiscrotum, sometimes waking the patient from sleep. It may radiate to the groin or loin, reflecting the embryological origin of the testis and its nerve supply). There may be a history of a blow to the testis in the hours before the acute onset of pain. Some patients report similar episodes occurring in the past, with spontaneous resolution of the pain, suggesting an episode of torsion with spontaneous detorsion. The patient will be in considerable pain, and may have a slight fever. Patients do not like the testis being touched and will find it difficult to walk and to get up on the examination couch, as movement causes pain. The testis is usually swollen, very tender to touch and may appear abnormally tense (if the patient lets you squeeze it!). It may be high-riding (lying at a higher than normal position in the testis) and may be in a horizontal position due to twisting of the cord. The testis may feel hard and there may be scrotal wall erythema.
The cremasteric reflex may be lost, although the presence or absence of this reflex should not be taken as reliable evidence either that the patient has a torsion or does not (Nelson et al. 2003). The cremasteric reflex may be elicited by stroking the finger along the inside of the thigh, which results in upward movement of the ipsilateral testis.