Parents, young boys, and men should be aware that any testicular pain is an emergency until there is proof suggesting otherwise. Testicular pain can be the first sign that the testicle has lost its blood supply. It can also be a sign of infection of testicle or the tube around the testicle (the epididymis) or death of tissue connected testis or epididymis within the scrotal sac. Pain in the testicular area can also be referred pain from a groin hernia or a kidney stone, trauma or rarely a testis tumor. In cases where none of the above diagnoses have been made, intermittent testicular torsion should be considered as a cause of the pain.

EMERGENCY SITUATION:
Testicular torsion and/or trauma to the testis are emergencies; therefore any male experiencing testicular pain should go to the emergency room (ER) immediately. Any general surgeon or urologist has received training to perform the testis saving procedure of untwisting the blood supply to the testicle and fixing the untwisted testicle within the scrotum. The ER will benefit from having an accurate timeline regarding the symptoms of pain and any other associated symptoms (nausea, vomiting, location, degree, etc) and or any relevant history of events (trauma, hydrocele, undescended testis, etc.). An ultrasound with Doppler should be completed urgently to assess the blood flow of both testes and find out as quickly as possible whether the patient needs to have repair surgery.

SYMPTOMS:
Testicular torsion happens when the testicle twists on its blood supply (like a chandelier not anchored to the floor) and pulls up or rolls up towards the groin and away from the scrotal skin within the scrotal sac. Simply put the testicle that twists on the blood supply is not anchored inside the scrotal skin. When this happens the testicle can move away from the scrotal skin as an entirely normal reflex (cremasteric) and get stuck, blocking the blood flow at the point of twisting. Pain is the response to this process and the male may experience testicular, scrotal, perineal, abdominal or groin pain initially which will eventually localize to the testicle. Common testicular pain symptoms associated with testicular torsion include nausea, vomiting, difficulty walking normally, jumping or balancing on one leg on the affected side. The pain can awaken the male from sleep, and may occur after a traumatic event or any level of physical activity. The testicle without blood return will swell. Over time the lack of oxygenated blood flow to the testicle will result in death of the testicle and the testicle will atrophy (or become smaller) and will likely become non functional. The overlying scrotal skin will respond to this process of tissue dying by becoming inflamed (that is thickened, red, warm, with decreased lines (or ruggae) and movement of the overlying scrotal skin). The cremasteric reflex (the movement of the testicle in response to touch of the inner thigh) will often cease (stop) as a result of the testicle being stuck and the overlying skin inflammation. It should be noted that the swelling or thickness of the scrotal skin may be a late sign, representing the death of the testicle within the scrotal sac.

OCCURRENCE:
Testicular torsion can happen any time of the year despite some calling it “winter’s disease”. It can occur at any age and stage of development: prenatal period and beyond. The most common population to experience testicular torsion is adolescent males (65% of torsion occurs between ages of 12 and 18 years of age in males) and this population is the focus of this document because the education of this age group, their parents/guardians and their pediatricians may prevent testicular loss, which is the most common and devastating consequence of testicular torsion in this population. These boys are vulnerable because they are often embarrassed, therefore reluctant to tell their parent(s)/guardian(s). Some boys going through puberty associate self stimulation or arousal with the onset of pain and believe their pain will go away if they wait it out. This is a wrong assumption. Persistent pain should prompt any male to go to an ER, because the likelihood of saving the testicle(s) after more than six hours from the onset of pain is rare. Parents/guardians may experience guilt especially when they realize that an emergency response is required to save the testis. Some parents have reported treating their male child for constipation or gas. Parent(s) guardian and general practitioners/pediatricians should educate and encourage prepubescent boys to perform self examinations and know their body well enough to recognize a change in their own physical exam. The testicle with twisted blood supply often feels differently than the normal testicle and the male’s response to being touched in the affected scrotal area is abnormal as well. So a physical exam of the genitals is important to perform when there are complaints of abdominal, genital, groin or perineal pain.

OUTLOOK:
It should be noted that even saved testicles can continue to atrophy (become smaller) and become poorly functional or completely non functional. Testicles without blood supply for greater than six hours have a significantly higher likelihood of death and atrophy than those managed beyond that period of time. Therefore, testicular torsion is a medical emergency and time is of the essence. In other words, death of the testicle or loss of testicular function when there is torsion is completely dependent on the time it takes, from the onset of pain until the testicle untwisted.

The most devastating situation is the loss of both testicles: for a prepubertal male this means they don’t get to go through puberty without injection of exogenous testosterone and they aren’t able to conceive children. One-sided or unilateral torsion does not have the same prognosis. Only one testicle is needed to undergo pubertal development and only one is needed to conceive children. Although there may be some impact on the fertility rate compared to having two testicles.

SUMMARY:
All males with testicular pain or swelling should seek a urology surgeon’s input for their child. Ideally, families with affected boys should quickly get to an ER where a physical exam and diagnostic ultrasound can be performed in a same facility where manual untwisting and fixation of the testicle within the scrotum can be done. The only relief of testis pain due to testicular torsion is untwisting of the blood supply to the testicle so that blood flow can return to the testicle. This may happen spontaneously or manually while the testicle is within the scrotum or during the surgical procedure intended to save the testicle and or secure the normal testicle from the same fate.

Definitions:
• Testis: the ball in the scrotal sac that is responsible for puberty because of testosterone production and for fertility through sperm production.
• Epididymis: the structure on posterior lateral part of the testis carrying very long convoluted tube. The epididymis is a single tube carrying a sperm to the urethra during sexual intercourse for conception.
• Scrotum: the area responsible for housing the testicle where it is 2 degrees cooler. The scrotum is generally the healthiest place for testicular development.
• Groin: the space border between the abdomen, genital and the inner thigh.
• Perineum: the area between scrotum and the anus.

WHAT TO EXPECT IN THE ER:
1. Ultrasound: used to rule out torsion, testicular ischemia or twisted blood supply to testicle.
2. Urine culture: urine specimen used to assess for infected urine.
3. Examination of the genitals.

TREATMENT:
• Include untwisting the testicle and fixing the testicle inside the scrotal skin on both sides.
• Remove the affected testicle if it is dead.
• Scrotal support for after surgery.
• Non-narcotic pain control is all that is needed. Narcotic medication pain control sometimes used, but rarely needed.
• Relief of pain usually comes from untwisting the testicle.
• Activity will be limited for a period of time after surgery.
• A conscious alternative is letting the testicle atrophy (smaller/non functional).