Similarly, the presence of a mass or malignancy involving the spermatic cord can also predispose to torsion.Age is also an important risk factor for torsion. Torsion most commonly occurs either in the newborn or just before or during puberty. Testicular torsion often occurs before or during puberty, prior to complete testicular descent. Epididymitis is more commonly a postpubertal condition.Several congenital anatomic malformations or variations in the testicle or the surrounding structures may allow for increased scrotal rotation and increase the risk of testicular torsion. A congenital malformation of the processus vaginalis known as "bell-clapper deformity" accounts for 90% of all cases. In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis. Other anatomic risk factors include horizontal lie of the testicle or a spermatic cord with a long intrascrotal portion. Cryptorchidisim is also a risk factor for torsion with some studies proposing a 10-fold higher risk. Testicular torsion may also be caused by trauma to the scrotum or exercise (in particular, bicycle riding), however only about 4-8% of cases are the result of trauma. There is thought to be a possible genetic basis for predisposition to torsion, based on multiple published reports of familial testicular torsion. There is controversy whether cold weather months are associated with an increased risk.
Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the blood supply to the testicle. The most common symptom in children is sudden, severe testicular pain. The testicle may be higher than usual in the scrotum and vomiting may occur. In newborns, pain is often absent and instead the scrotum may become discolored or the testicle may disappear from its usual place.Most of those affected have no obvious prior underlying health problems. Testicular tumor or prior trauma may increase risk. Other risk factors include a congenital malformation known as a "bell-clapper deformity" wherein the testis is inadequately attached to the scrotum allowing it to move more freely and thus potentially twist. Cold temperatures may also be a risk factor. The diagnosis should usually be made based on the presenting symptoms, but requires timely diagnosis and treatment to avoid testicular loss. An ultrasound can be useful when the diagnosis is unclear.Treatment is by physically untwisting the testicle, if possible, followed by surgery. Pain can be treated with opioids. Outcome depends on time to correction. If successfully treated within six hours onset, it is often good. However, if delayed for 12 or more hours the testicle is typically not salvageable. About 40% of people require removal of the testicle.It is most common just after birth and during puberty. It occurs in about 1 in 4,000 to 1 in 25,000 males under 25 years of age each year.