Severe pain in the scrotum during a soccer game sent a 14-year-old boy to his physician. The right testicle was swollen and exquisitely tender. On exploration, it was hemorrhagic and blue-black. A small incision in the tunica of the testis revealed arterial bleeding, which indicated that the testis was still viable. The right testicle was untwisted and fixed to the scrotum. The contralateral testicle was explored and fixed to the scrotum to prevent torsion.
Torsion of the testis is caused by abnormal fixation of the testis to the scrotum. Under normal circumstances, the tunica vaginalis covers the sides and anterior aspect of the testis. The back of the epididymis and the posterior surface of the testis are not covered by the tunica vaginalis. A normal testis is thus fixed within the tunica and cannot twist. When the tunica vaginalis covers not only the testis but also the epididymis and the distal part of the spermatic cord, the testis can twist with ease, especially when aided by contraction of the spiral fibers of the cremaster muscle. This abnormality of the tunica vaginalis is often bilateral.
Torsion of the testis occurs when the testis and spermatic cord twist, resulting in testicular ischemia. If not treated promptly, this condition may lead to gangrene of the testis. If the testis is still viable, it should be fixed to the scrotum. A necrotic testis is best removed, since it will have no hormonal or reproductive function. The contralateral testis should be fixed to the scrotum to prevent torsion.