503212

research-article2013

JDMXXX10.1177/8756479313503212Journal of Diagnostic Medical SonographyPatel et al.

Case Study

Partial Testicular Torsion and

Torsion-Detorsion Syndrome

Journal of Diagnostic Medical Sonography

29(5) 225231
The Author(s) 2013
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/8756479313503212
jdms.sagepub.com

Nayana U. Patel, MD1, Julia A. Drose, BA, RDMS, RDCS, RVT2,

and Paul Russ, MD1

Abstract
Testicular torsion (TT) is a common cause of acute scrotal pain in young men and accounts for as many as 26% of cases
of acute scrotum. Accurate diagnosis and differentiation of TT from acute epididymo-orchitis is essential because TT
is treated surgically and epididymitis with or without orchitis is treated medically. Distinguishing TT from epididymoorchitis is generally a clinical dilemma. Sonography remains the best imaging modality for these entities, but the
sonographic findings can be complex and can mimic complicated epididymo-orchitis when dealing with partial TT and
torsion-detorsion syndrome. This case report illustrates the complex sonography findings of surgically proven partial
TT with torsion-detorsion syndrome.
Keywords
scrotal ultrasound, Doppler, testicular pain, partial testicular torsion, torsion-detorsion syndrome

Introduction

Case Report

Testicular torsion (TT) is a true urologic emergency and

must be differentiated from other causes of acute testicular pain because a delay in diagnosis and management can lead to loss of the testis and infertility.15
Testicular torsion can occur at any age but commonly
affects 1 in 4000 males younger than 25 years old each
year.1,4 Diagnosis of partial testicular torsion (PTT) and
torsion-detorsion syndrome (TDS) is challenging as
changes in the testis depend on the duration of torsion
and the degree of rotation of the spermatic cord. Torsiondetorsion syndrome or intermittent testicular torsion
(ITT) is defined as acute and intermittent sharp testicular pain due to impeded blood flow, interspersed with
asymptomatic intervals. Sonography remains the best
imaging modality to evaluate for acute scrotal pain.1,68
However, there is overlap in the gray-scale and Doppler
findings of epididymo-orchitis (EO) and PTT with TDS,
and testicular or paratesticular hyperemia during the
detorsion phase of TDS can be confused with complicated EO.5,8,9 The clinical presentation of TT and acute
EO also is often similar. Diagnosis of ITT is important
as these patients are at high risk to develop acute torsion. Intermittent spermatic cord torsion can be treated
with elective testicular fixation. Misdiagnosis or delay
in diagnosis may create acute unresolved torsion and
potential testicular loss.10

A 43-year-old man presented to the emergency department due to sudden onset of sharp left testicular pain. The
patients history was significant for recent EO, which was
treated with antibiotics 2 weeks prior. At this visit, he was
given intravenous (IV) Ciprofloxacin for a clinical diagnosis of EO; the patient remained stable without sharp
pain and was discharged home with pain medication.
The patient returned to the emergency department a
few hours later with uncontrolled left scrotal pain, low
grade fever, and leukocytosis with a white blood cell count
of 17.7. On physical examination, his left testis was swollen, erythematous, and tender to palpation. A clinical diagnosis of EO was again made, however, scrotal sonography
was ordered to exclude TT. Scrotal sonography was performed utilizing a Philips iU-22 ultrasound system
(Philips Medical Systems; Bothell, WA) with a 12-5 MHz
1

Department of Radiology, University of Colorado School of

Medicine, Aurora, CO, USA
2
Divisions of Ultrasound and Prenatal Diagnosis and Genetics,
University of Colorado School of Medicine, Aurora, CO, USA
Corresponding Author:
Nayana U. Patel, MD, Department of Radiology, University of
Colorado School of Medicine, Anschutz Medical Campus, 12401 E.
17th Avenue, Mail Stop L954, Aurora, CO 80045-2548, USA.
Email: Nayana.Patel@ucdenver.edu

226

Journal of Diagnostic Medical Sonography 29(5)

Figure 1. Transverse images of the testes showing symmetrical size and normal echogenicity.

Figure 2. Longitudinal image of the right testis with normal

blood flow by color Doppler.

Figure 3. Longitudinal image of the left testis showing slightly

increased flow by color Doppler compared to the right side.

linear transducer. Color Doppler imaging and spectral

Doppler velocity measurements were done in addition to
gray-scale imaging. Gray-scale images showed the testes
to be symmetric, with normal echogenicity (Figure 1).
Color Doppler imaging showed normal blood flow in the
right testis (Figure 2), slightly increased blood flow in the
left testis (Figure 3), and diffusely increased blood flow in
the left epididymis (Figure 4). Spectral Doppler evaluation showed a normal low resistance arterial flow waveform in the right testis (Figure 5). Areas of absent (Figure

6) and reversed (Figure 7) diastolic flow were noted within

the left testis. Differential diagnosis based on the sonographic features was severe complicated EO versus partial
and intermittent testicular torsion.
The patient was admitted to the urology service and
started on IV antibiotics. Urine and blood cultures were
negative. A few hours later, physical examination showed
that the left testis had become larger and extremely tender, with associated scrotal edema, and the patients
symptoms continued to worsen despite IV antibiotics. A

227

Patel et al.

Figure 4. Longitudinal image of the body of the left

epididymis showing marked diffuse hyperemia (black arrow)
by color Doppler.

Figure 7. Spectral Doppler of the left testis in a different

location showing reversal of diastolic flow (white arrow).

Figure 5. Normal spectral Doppler sonography of the

asymptomatic right testis showing low resistance arterial flow.
Normal diastolic flow is indicated by white arrow. Normal
systolic peak is indicated by red arrow.
Figure 8. Transverse image on follow-up sonography
showing normal symmetry and echogenicity of the testes.

Figure 6. Spectral Doppler of the left testis showing absent

diastolic flow (white arrow).

repeat sonogram was performed 4 hours later to re-evaluate

the left testis. Echogenicity of the left testis remained normal and isoechoic to the right testis (Figure 8). Color and
spectral Doppler examination again showed normal blood
flow in the right testis with a normal low resistance arterial flow waveform (Figures 9 and 10). Decreased blood
flow was seen in the left testis (Figures 11 and 12); additional findings of note were increased left scrotal wall
thickening with associated hyperemia (Figure 12) and a
left hydrocele (Figure 13). Decreased diastolic flow was
seen in the left testis; however, diastolic flow reversal in
the left testis was no longer appreciated (Figure 13).
Venous flow within the left testis was present (Figure 14).

228

Figure 9. Longitudinal image of the right testis on follow-up

showing normal flow by color Doppler.

Journal of Diagnostic Medical Sonography 29(5)

Figure 11. Transverse image of the testes on follow-up

sonography showing decreased flow on the left side by color
Doppler.

Figure 10. Follow-up spectral Doppler image of the right

testis showing a normal low resistance arterial waveform.

A diagnosis of PTT and TDS was made based on the

clinical and sonographic findings, and the patient was
immediately taken to surgery. At surgery, the left testis
was dusky with poor blood flow and a left orchiectomy
was done. A right orchiopexy was performed prophylactically to prevent torsion. Histopathology of the left orchiectomy specimen showed tubules with normal
spermatogenesis, marked interstitial edema and hemorrhage, and early necrosis of the interstitial cells of Leydig
consistent with torsion (Figure 15).

Discussion
The most important objective in patients with sharp,
acute scrotal pain is to exclude or confirm TT. The

Figure 12. Longitudinal follow-up image of the left testis

showing decreased flow by color Doppler. Reactive left
scrotal wall thickening with hyperemia (black arrow) is also
appreciated. Note no hyperemia of the epididymis.

differential diagnosis of the acutely painful scrotum

includes TT, trauma, epididymitis/orchitis, incarcerated
hernia, and torsion of the appendix testis.9 Accurate clinical distinction between TT and EO is difficult in up to
50% of cases and is generally a clinical dilemma. The
differentiation between these two entities is crucial
because TT is treated surgically and epididymitis with or
without orchitis is treated medically. Testicular torsion
requires urgent intervention to avoid organ loss and infertility. The optimal time frame for testicular salvage is less
than 6 hours after the onset of symptoms.5,9

229

Patel et al.

the degree of rotation of the spermatic cord. Ischemia can

occur as soon as 4 hours after torsion and is almost certain after 24 hours.3,4
Ipsilateral absent cremasteric reflex is the most accurate sign of TT on clinical examination.11 This reflex is a
contraction of the cremaster muscle in response to lightly
stroking the inner upper thigh (via the sensory and motor
fibers of the genitofemoral nerve); this muscle contraction elevates or pulls up the testis on the side stroked. On
physical examination, horizontal lie of the affected testis
with the patient in a standing position may also suggest
the diagnosis of ITT.2

Sonography
Figure 13. Follow-up spectral Doppler image of the left
testis showing a high resistive index, with no diastolic flow
(white arrow) and a hydrocele (red arrow).

Figure 14. Follow-up spectral Doppler image showing

venous flow in left testis.

Testicular Torsion
The annual incidence of TT is 1 in 4000 males younger
than 25 years.14 Torsion of the spermatic cord usually
occurs in the absence of any precipitating event. Only 4%
to 8% of cases are a result of trauma. Other factors predisposing patients to TT include an increase in testicular volume (often associated with puberty), testicular tumor,
testis with a horizontal lie, a history of cryptorchidism,
and a spermatic cord with a long intrascrotal portion.2,3,5
Torsion of the spermatic cord initially obstructs venous
return. Subsequent equalization of venous and arterial
pressures compromises arterial flow, resulting in testicular ischemia. The degree of ischemia and resultant
changes in the testis depend on the duration of torsion and

The sensitivity of color flow Doppler to TT in pediatric

patients is 90% to 100%, and specificity is nearly 100%.
In the adult population, a similar sensitivity of 80% to
98% and specificity of 97% to 100% have been
reported.1,12 The sensitivity of spectral Doppler ranges
from 67% to 100%. An understanding of normal blood
flow to the testes is important in interpreting color
Doppler and spectral Doppler waveforms in the setting of
TT. The normal spectral waveform of the testicular artery
has low-resistance flow. Resistive indices (RIs) in normal
intratesticular arteries range from 0.48 to 0.75 with a
mean of 0.62.13
Gray-scale and Doppler findings in TT include the
following:1,6,8
Normal echogenicity of the testis in the early
phase.
Hypoechoic testis after 4 to 6 hours secondary to
edema.
Heterogeneous testis after 24 hours secondary to
hemorrhage and infarction.
Reactive hydrocele and skin thickening.
Enlarged twisted spermatic cord superior to the
symptomatic testiswhirlpool sign.
Decreased or absent flow in symptomatic testis.
Normal or decreased flow in testis with incomplete torsion (<360 degrees).
Normal or increased flow in testis and paratesticular
soft tissues from reactive hyperemia with detorsion.
Absence of a dicrotic notch resulting in a monophasic waveform on spectral Doppler.
Increased resistance to arterial flow with a decrease
in diastolic flow velocity on spectral Doppler.
Reversal of diastolic flow on spectral Doppler.14,15
In the small case series by Cassar and colleagues, most
of the cases of PTT were diagnosed only after careful
examination of the morphologic and spectral Doppler

230

Journal of Diagnostic Medical Sonography 29(5)

Figure 15. Histology of the left testis following orchiectomy showing significant interstitial edema and hemorrhage
(a, 2 magnification) with early necrosis noted of the interstitial cells of Leydig (b, 20 magnification).

waveform characteristics as compared to the contralateral

testis or a different region within the same testis.6
Identification of a sonographic whirlpool sign
related to twisting of the spermatic cord is reported to be
the most specific and sensitive sign of both complete and
incomplete torsion and may help to make a definite diagnosis.16,17 The whirlpool sign is an acute rotation of the
spermatic cord observed while scanning its transverse
plane in which the spermatic cord looks twisted or spiraled, similar to a whirlpool.

Treatment
Treatment of TT involves rapid restoration of blood flow
to the affected testis. The optimal time frame is less than
6 hours after the onset of symptoms. In one study, investigators quoted a testicular salvage rate of 90% if detorsion occurred less than 6 hours from the onset of
symptoms; this rate fell to 50% after 12 hours and to less
than 10% after 24 hours.18 Manual detorsion by external
rotation of the testis can be successful, but restoration of
blood flow must be confirmed following the maneuver.
Surgical exploration provides definitive treatment for the
affected testis by orchiopexy and allows for prophylactic
orchiopexy of the contralateral testis.

Epididymitis and Epididymo-Orchitis

Epididymitis and epididymo-orchitis are also common
causes of acute scrotal pain in adolescent boys and
adults.9 In adolescents, many instances are secondary to
sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhea. In prepubertal boys
and in men older than 35 years of age, the disease is most
frequently caused by Escherichia coli and Proteus

mirabilis. The epididymis is the organ primarily involved

in EO, with orchitis developing in 20% to 40% of cases
due to direct spread of infection.
Early in the course of the disease, on physical examination the epididymis can be palpated as an enlarged tender structure separate from the testis. Scrotal pain
associated with epididymitis is usually relieved when the
testes are elevated over the symphysis pubis (the Prehn
sign). This sign may help clinically differentiate between
epididymitis and torsion of the spermatic cord, in which
scrotal pain is not lessened with this maneuver.

Sonography
The sensitivity of color Doppler imaging in detecting
scrotal inflammation is nearly 100%. In 20% of cases of
epididymitis and 40% of cases of orchitis, hyperemia is
seen with color Doppler even when gray-scale findings
are normal.7,9
Gray-scale and Doppler findings include the following:
Enlarged hypoechoic or hyperechoic epididymis
(presumably secondary to hemorrhage).
Reactive hydrocele or pyocele with scrotal wall
thickening.
Testicular enlargement and a heterogeneous testicular echotexture.
Hyperemia of the epididymis and testis with color
Doppler.
Decreased vascular resistance on spectral Doppler.
Reversal of flow during diastole, suggestive of
venous infarction.19
Increased RIs and reversed diastolic flow have been
reported in PTT, and also as a complication with severe

Patel et al.
EO.6,17,19 In severe EO, reversal of diastolic flow is caused
by swelling and edema occluding the venous outflow and
implies the risk of impending infarction.

Conclusion
The diagnosis of PTT and TDS in this case was not appreciated on the first sonogram due to the presence of arterial
and venous flow and testicular/paratesticular hyperemia,
all of which may be seen with acute EO. Careful examination of the morphologic characteristics and amplitude
of the spectral Doppler waveform is essential to help
make the diagnosis of this entity. Looking for a sonographic whirlpool sign should be part of the evaluation
when vascular flow is present on the symptomatic side.
Detorsion is more likely in the presence of spontaneously
resolved acute scrotal pain and hyperemia on color
Doppler imaging. When the clinical and sonography features are inconclusive between EO and PTT with TDS,
the patient may benefit from active follow-up.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.

References
1. Dogra VS, Bhatt S, Rubens DJ: Sonographic evaluation of
testicular torsion. Ultrasound Clin 2006;1:5566.
2. Creagh TA, McDermott TE, McLean PA, Walsh A:
Intermittent torsion of the testis. BMJ 1988(6647);297:525
526.
3. Sellu DP, Lynn JA: Intermittent torsion of the testis. J R
Coll Surg Edinb 1984;29(2):107108.
4. Stillwell TJ, Kramer SA: Intermittent testicular torsion.
Pediatrics 1986;77(6):908911.

231
5. Ringdahl E, Teague L: Testicular torsion. Am Fam
Physician 2006;74(10):17391743.
6. Cassar S, Bhatt S, Paltiel HJ, Dogra VS: Role of spectral
Doppler sonography in the evaluation of partial testicular
torsion. J Ultrasound Med 2008;27(11):16291638.
7. Dogra VS, Rubens D, Gottliebs R, Bhatt S: Torsion and
beyond, new twists in spectral Doppler evaluation of the
scrotum. J Ultrasound Med 2004;23(8):10771085.
8. Lin EP, Bhatt S, Rubens DJ, Dogra VS: Testicular torsion:
twists and turns. Semin US CT MR 2007;28(4):317328.
9. Dogra VS, Bhatt S: Acute painful scrotum. Radiol Clin
North Am 2004;42(2):349363.
10. Hayn MH, Herz DB, Bellinger MF, Schneck FX:

Intermittent torsion of the spermatic cord portends
an increased risk of acute testicular infarction. J Urol
2008;180(4 Suppl):17291732.
11. Paul EM, Alvayay C, Palmer LS: How useful is the cremasteric reflex in diagnosing testicular torsion? J Am Coll Surg
2004;199(3 Suppl):101.
12. Prando D: Torsion of the spermatic cord: the main grayscale and Doppler sonographic signs. Abdom Imaging
2009;34(5):648661.
13. Middleton WD, Thorne DA, Melson GL: Color Doppler
ultrasound of the normal testis. AJR Am J Roentgenol
1989;152:293297.
14. Dogra VS, Sessions A, Mevorach RA, Rubens DJ:

Reversal of diastolic plateau in partial testicular torsion. J
Clin Ultrasound 2001;29(2):105108.
15. Sanders LM, Haber S, Dembner A, Aquino A: Significance
of reversal of diastolic flow in the acute scrotum. J
Ultrasound Med 1994;13(2):137139.
16. Vijayaraghavan SB: Sonographic differential diagnosis of
acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med 2006;25:563574.
17. Arce JD, Cortes M, Vargas JC: Sonographic diagnosis of
acute spermatic cord torsion. Rotation of the cord: a key to
the diagnosis. Pediatr Radiol 2002;32(7):485491.
18. Barada JH, Weingarten JL, Cromie WJ. Testicular salvage
and age-related delay in the presentation of testicular torsion. J Urol 1989;142:746748.
19. Gerscovich EO, Bateni CP, Kazemain MR, Gillen MA,
Visis T: Reversal of diastolic blood flow in the testis of
a patient with impending infarction due to epididymitis. J
Ultrasound Med 2008;27(11):16431646.

504376

research-article2013

JDMXXX10.1177/8756479313504376Journal of Diagnostic Medical SonographyJDMS CME ArticleSDMS CME Credit

JDMS CME Article-SDMS

CME Credit
available to SDMS Members Only

SDMS members can earn FREE SDMS CME credit by reading this approved CME
article and successfully completing the online CME test. If you are not a current SDMS
member but would like to earn SDMS CME credit, please visit http://www.sdms.org/
members/login.asp to join SDMS.
Instructions
1. Each question has only one correct answer.
2. Go online to http://www.sdms.org/members/login.asp to score your test answers (SDMS membership number required). NO JDMS CME tests will be accepted by mail or FAX.
3. You will receive your test score results immediately*if you achieve a score of 70% or better, SDMS CME
credit will be awarded.
4. Awarded CME credits are tracked in the SDMS CME Tracker system. For more information about the SDMS
CME Tracker system, visit http://www.sdms.org/members/login.asp.
*Because the correct answers will be provided after you submit your answers, only one attempt is permitted to
successfully complete the JDMS CME article test. Please verify your answers before submission.

Article: Partial Testicular Torsion and Torsion-Detorsion

Syndrome
Authors: Nayana Patel, MD, Julia A. Drose, BA, RDMS,
RDCS, RVT, and Paul Russ, MD
Category: Abdomen/Small Parts
Credit: 1.0 SDMS CME Credit
Objectives: After studying the article entitled Partial
Testicular Torsion and Torsion-Detorsion Syndrome,
you will be able to:
1. Differentiate testicular torsion from epididymoorchitis using duplex ultrasound
2. Describe the hemodynamic changes associated
with prolonged testicular torsion
3. Quantify spectral Doppler changes seen in testicular torsion
1.Because of similar signs and symptoms, clinical
differentiation of testicular torsion and epididymoorchitis may be difficult in approximately what
percentage of cases?
a.40%
b.50%

c.60%
d.70%
2.In the male population younger than 25 years, the
annual incidence of testicular torsion is approximately one in
a.4000
b.5000
c.6000
d.7000
3. Treatment of testicular torsion is typically
a. Careful observation
b. Pain medication
c. The Prehn maneuver
d.Surgery
4.The optimal window for definitive treatment of testicular torsion from the time of onset of symptoms
is less than
a. 6 hours
b. 12 hours
c. 18 hours
d. 24 hours

JDMS CME ArticleSDMS CME Credit

233

5.Gray-scale sonographic findings in testicular torsion may include all of the following except
a. Normal early phase echogenicity
b.Hyperechogenicity secondary to 4 to 6 hours
of ischemia
c.
Heterogeneous echogenicity secondary to
infarction after 24 hours
d. A reactive hydrocele

8.Characteristic color and spectral Doppler changes

associated with testicular torsion include all of the
following except
a. Overall decreased flow in the affected testis
b. Decreased diastolic flow on spectral Doppler
c.An exaggerated dicrotic notch in the spectral
Doppler waveform
d. An increase in the arterial resistive index

6.The average normal resistive index in the intratesticular arteries is approximately

a.0.45
b.0.52
c.0.62
d.0.78

9.Spread of infection of epididymitis will lead to

orchitis in approximately what percentage of cases?
a.10%20%
b.20%40%
c.40%60%
d.60%70%

7.The initial hemodynamic change associated with

testicular torsion is
a. Arterial narrowing with decreased flow
b.
Arteriolar constriction elevating vascular
resistance
c. Arterial occlusion causing ischemia
d. Venous obstruction

10.Except in cases of very severe epididymo-orchitis,

the distinguishing hemodynamic characteristic of
epididymo-orchitis that differentiates it from testicular torsion is
a. Decreased diastolic flow on spectral Doppler
b.A multiphasic flow signal typical of peripheral
arteries
c. Hyperemic, low-resistance flow in the testis
d. A to-and-fro flow pattern