#EMConf: Testicular Torsion

Epidemiology - Peak incidence in first year of life and during puberty; Can occur at any age.

Mechanism - 50% occur during sleep; Can occur during trauma as well. 

Risk factors - Bell-clapper deformity or undescended testes. 


  • acute onset testicular pain, associated nausea and vomiting. 
  • can present with isolated lower abdominal pain or flank pain. 
  • exam findings are not very sensitive
    • cremasteric reflex
    • phren's sign does not rule out torsion
    • swollen testes, transverse lie. 
    • blue dot sign pathognomonic for torsion of appendix testis. 


  • History and physical exam are insufficient to rule out testicular torsion - ultrasound. 
  • stat urology consult.
  • UA
  • consider manual detorsion depending on urology consultation. 

How We Miss Torsion:

  • One of the four most common sources of pediatric malpractice litigation. 
  • Failing to recognize it can occur after puberty. 
  • atypical presentations like lower abdominal pain.
  • not examining the testicles in every GU and lower abdominal pain complaint. 
  • false negative torsion is a common theme in litigated and missed torsion cases - if negative ultrasound but high clinical suspicion consult urology.