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Introduction

Testicular torsion is a urologic emergency characterized by twisting of the testis on the spermatic cord, leading to obstruction of blood flow and testicular ischemia.  The classic presentation is sudden-onset, severe, unilateral testicular pain, often with nausea and vomiting.  A swollen, tender scrotum and an elevated, transverse testicle are typical examination findings; the cremasteric reflex is characteristically absent.  Doppler ultrasonography confirms the diagnosis, and treatment is with immediate surgical detorsion.

Anatomy and pathophysiology

The lower pole of the testicle is normally well adhered to the tunica vaginalis ( Figure 1), a fascial layer within the scrotal sac.  This connection inhibits mobility of the testis on the spermatic cord, which contains the testicular blood vessels (branches of the abdominal aorta).

Inadequate fixation of the testis to the tunica vaginalis during embryologic development causes the oval testis to rest in a horizontal (rather than the normal vertical) plane (ie, bell clapper deformity (

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