Testicular Torsion

Table of Contents

  1. Overview
  2. Types and Pathophysiology
  3. Epidemiology
  4. Clinical Presentation
  5. Diagnosis
  6. Differential Diagnosis
  7. Treatment
  8. Time-to-Treatment and Salvage Rates
  9. Prognosis and Complications
  10. Prevention and Prophylactic Orchiopexy
  11. Research and Key Findings
  12. References
  13. Connections
  14. Featured Videos

1. Overview

Testicular torsion is a surgical emergency caused by twisting of the spermatic cord, which cuts off the blood supply to the testis. As the cord rotates, the testicular artery is compressed, leading rapidly to ischemia and — if not relieved within hours — to irreversible infarction and loss of the testis. It accounts for approximately 25–35% of acute scrotal pain presentations in emergency departments and represents one of the most time-critical urological emergencies in medicine.

The central principle governing management is deceptively simple but frequently violated in clinical practice: when testicular torsion is clinically suspected, the patient goes to the operating room immediately. Every hour of delay exponentially worsens the odds of saving the testicle. The difference between a six-hour and a twelve-hour delay is the difference between near-certain salvage and a coin flip. This time-dependency makes testicular torsion a condition where rapid clinical recognition, not sophisticated diagnostic workup, is the primary determinant of outcome.

Testicular torsion predominantly affects two age groups — neonates and adolescents — and understanding which anatomical variant occurs in each group is essential for correct diagnosis and surgical planning. Both forms share the same final common pathway of spermatic cord twisting and ischemia, but they differ in predisposing anatomy, clinical presentation, and surgical findings.

2. Types and Pathophysiology

Intravaginal Torsion (Most Common)

Intravaginal torsion occurs when the testicle rotates within the tunica vaginalis — the serous sac enclosing the testis and lower spermatic cord. This is by far the most common form, accounting for the overwhelming majority of cases after the neonatal period. It is directly predisposed by the "bell clapper" deformity, an anatomical variant present in approximately 12% of males.

In normal anatomy, the tunica vaginalis attaches to the posterior aspect of the testis and lower epididymis, anchoring the testis firmly to the posterior scrotal wall and preventing free rotation. In the bell clapper deformity, the tunica vaginalis attaches abnormally high on the spermatic cord, leaving the testis and epididymis suspended freely within the tunic like a clapper hanging inside a bell. With no posterior fixation, the testis is free to swing and rotate on the spermatic cord, just as a bell's clapper swings within its housing. The torsion typically involves 360–720 degrees of rotation, but even 180 degrees can be sufficient to occlude the testicular artery under tension.

The bell clapper deformity is bilateral in approximately 80% of cases. This is the anatomical basis for the cardinal surgical rule that bilateral orchiopexy is performed even when only one testis has torsed — the contralateral testis is at equivalent anatomical risk and will torse without fixation.

Once the cord twists, venous outflow is obstructed first (veins have lower intraluminal pressure and are more easily compressed), producing venous congestion, edema, and rising intratesticular pressure. Arterial inflow is compromised next as intratesticular pressure exceeds arterial perfusion pressure. Ischemia progresses to infarction in a time-dependent manner determined by the degree of rotation, individual anatomical variation, and extent of collateral supply. The testicular parenchyma is highly metabolically active and has among the lowest ischemic tolerance of any organ — substantially less tolerant than the heart or brain.

Extravaginal Torsion

Extravaginal torsion occurs outside the tunica vaginalis and is almost exclusively a neonatal condition, typically occurring in the perinatal period (before, during, or shortly after birth). In the neonate, the tunica vaginalis and its investment of the testis is not yet firmly attached to the scrotal wall, allowing the entire tunic — together with the testis and epididymis inside it — to rotate en masse on the spermatic cord. This is distinct from intravaginal torsion, in which the testis rotates within a fixed tunica.

Prenatal extravaginal torsion presents at birth with a hard, non-tender, discolored hemiscrotum and a non-transilluminating scrotal mass. Because the torsion occurred in utero, the testis is typically already infarcted by the time of delivery, and salvage is almost never possible. Postnatal extravaginal torsion — occurring in the first weeks of life — can be salvageable if recognized and operated upon urgently. Unlike intravaginal torsion, the bell clapper deformity is not a prerequisite for extravaginal torsion; the condition results from incomplete fixation of the gubernaculum and tunica to the scrotal wall during scrotal descent.

Torsion of the Appendix Testis

A third, non-emergency form involves torsion of the appendix testis (hydatid of Morgagni) — a small embryological Müllerian duct remnant attached to the upper pole of the testis. This causes localized ischemia of the appendage rather than the testis itself and is not a threat to testicular viability. It can be difficult to distinguish from true testicular torsion clinically, particularly in younger children, and is discussed further in the Differential Diagnosis section.

3. Epidemiology

Testicular torsion has an estimated annual incidence of approximately 4 per 100,000 males under age 25, making it the most common cause of testicular loss in young men. The lifetime risk is approximately 1 in 4,000 males. The age distribution is distinctly bimodal, with two peaks separated by a relatively low-incidence interval in childhood:

Beyond the neonatal and adolescent peaks, testicular torsion can occur at any age, including in adults and elderly men, though it is uncommon. A retained or undescended testis (cryptorchidism) carries a substantially higher risk of torsion than a scrotal testis, because the undescended testis lacks the normal scrotal fixation that limits rotation. Torsion of an undescended testis presents as acute lower abdominal or inguinal pain with an empty hemiscrotum and requires a high index of suspicion.

Although torsion is classically described as spontaneous and idiopathic, it may be precipitated by vigorous physical activity, minor scrotal trauma, sexual activity causing cremasteric muscle contraction, or even cold temperature (which triggers cremasteric reflex contraction). Many episodes awaken patients from sleep, likely reflecting cremasteric reflex activity during sleep transitions.

4. Clinical Presentation

Symptoms

The hallmark presentation is sudden onset, severe, unilateral scrotal pain — typically beginning abruptly without prodrome and reaching maximum intensity within minutes. The pain may be described as a sharp, tearing, or twisting sensation. It is important to recognize that the pain of testicular torsion does not start gradually and worsen over hours the way epididymo-orchitis often does; the sudden-onset quality is one of the most clinically useful distinguishing features.

Nausea and vomiting accompany the scrotal pain in a majority of patients — up to 60–70% in some series — and their presence in a young male with acute scrotal pain substantially raises the probability of torsion over inflammatory causes. Nausea reflects the rich visceral afferent supply of the testis (T10–L1 sympathetic fibers), the same neural pathway responsible for the referred flank and abdominal pain of renal colic. Some patients present with predominantly lower abdominal or inguinal pain and may mislead clinicians who do not examine the scrotum.

Lower urinary tract symptoms — dysuria, frequency — are typically absent in torsion (their presence favors epididymo-orchitis or UTI). Fever may develop late in the course but is not an early feature of torsion. A history of prior similar episodic scrotal pain that resolved spontaneously ("intermittent torsion" with spontaneous detorsion) is an important clue that the patient has the bell clapper deformity and is at risk for sustained torsion.

Physical Examination

Examination findings in testicular torsion are pathognomonic when classic, but can be subtle or partially attenuated in the setting of severe pain or early presentation:

5. Diagnosis

Clinical Diagnosis First

Testicular torsion is fundamentally a clinical diagnosis, and the single most important diagnostic principle is: do not delay surgical exploration in order to obtain imaging when the clinical diagnosis is secure. A young male with sudden-onset severe unilateral scrotal pain, an absent cremasteric reflex, and a high-riding testis has testicular torsion until proven otherwise. The operating room is faster and more definitive than any imaging study, and every minute of additional delay incrementally reduces the probability of salvage.

The decision threshold for emergency surgery should be set low. In adolescent males presenting with acute scrotal pain, the base rate of torsion is high enough — approximately 25–40% in emergency department series — that the expected value of immediate exploration exceeds that of imaging-first pathways when clinical suspicion is moderate to high. A useful clinical scoring system (the TWIST score — Testicular Workup for Ischemia and Suspected Torsion) assigns points for testicular swelling, hard testis, absent cremasteric reflex, nausea/vomiting, and high-riding testis: scores ≥5 go directly to surgery, scores ≤2 can be evaluated with ultrasound, and intermediate scores (3–4) require clinical judgment.

Color Doppler Ultrasound

When the clinical picture is equivocal — for example, in a patient with mild scrotal discomfort, present cremasteric reflex, and a low-intermediate TWIST score — color Doppler ultrasound is the imaging modality of choice. It is non-invasive, rapid, and available in most emergency departments. Key findings:

Critical caveats: (1) Normal or even increased flow does not exclude torsion — partial torsion with incomplete cord occlusion and reactive hyperemia can produce false-negative Doppler results, particularly in neonates and in early torsion. (2) A positive clinical examination (absent cremasteric, high-riding testis, sudden onset) overrides a negative Doppler — proceed to surgery. (3) Ultrasound must never delay surgical exploration when torsion is clinically probable.

Radionuclide Imaging

Technetium-99m pertechnetate testicular scintigraphy — historically an alternative to Doppler ultrasound — shows a photopenic (cold) area on the affected side. It has largely been supplanted by Doppler ultrasound due to the latter's superior speed, availability, lack of radiation, and ability to assess testicular morphology simultaneously. Scintigraphy retains a role in a small number of equivocal cases at centers where it is rapidly available.

6. Differential Diagnosis

Epididymo-Orchitis

The most important differential diagnosis. Epididymo-orchitis is an infection or inflammation of the epididymis (and often the adjacent testis), caused by ascending uropathogens — typically Chlamydia trachomatis or Neisseria gonorrhoeae in sexually active men under 35, and gram-negative Enterobacteriaceae (especially E. coli) in older men with underlying urological disease. Key distinguishing features favoring epididymo-orchitis over torsion:

When clinical features are mixed or equivocal, early scrotal exploration is preferable to risking an unrecognized torsion masquerading as epididymo-orchitis. The surgical mortality of scrotal exploration is negligible; the cost of a missed torsion is testicular loss.

Torsion of the Appendix Testis

The appendix testis (hydatid of Morgagni) is a 2–5 mm embryological remnant attached to the upper pole of the testis. Torsion of this appendage produces localized ischemia of the appendage itself — not the testis — and is therefore not a surgical emergency in the sense that testicular viability is not threatened. It is the most common cause of acute scrotal pain in prepubertal boys (ages 7–12 years).

The characteristic finding is the "blue dot sign" — a tender, bluish-purple discoloration visible through thin prepubertal scrotal skin at the upper pole of the testis, corresponding to the infarcted appendage. Pain is typically less severe than in testicular torsion, onset is less abrupt, and the cremasteric reflex is usually present. Doppler ultrasound confirms normal testicular perfusion with a small avascular nodule at the upper pole. Management is conservative — analgesics and scrotal support — with resolution over 7–10 days as the appendage undergoes autoinfarction. Surgical excision is reserved for cases with intractable pain.

The key risk is mistaking appendage torsion for early testicular torsion. When doubt persists after clinical and ultrasound evaluation, surgical exploration remains preferable to conservative observation.

Henoch-Schönlein Purpura (IgA Vasculitis)

Henoch-Schönlein purpura (HSP), now termed IgA vasculitis, is a small-vessel vasculitis affecting predominantly children aged 3–15 years, characterized by the tetrad of palpable purpura (lower extremities and buttocks), arthritis/arthralgia, abdominal pain, and renal involvement (IgA nephropathy). Scrotal involvement — occurring in up to 15–35% of boys with HSP — causes scrotal pain, swelling, and erythema from vasculitic inflammation of scrotal skin and underlying structures. The presence of the characteristic non-blanching purpuric rash on the lower extremities, typically preceding or accompanying scrotal symptoms, is the key diagnostic clue. Doppler ultrasound shows preserved or increased testicular blood flow, distinguishing HSP scrotal involvement from torsion.

Incarcerated Inguinoscrotal Hernia

An inguinal hernia with bowel or omentum descending into the scrotum can produce acute scrotal pain and swelling, particularly in infants and young children. Physical examination reveals a scrotal mass that may extend into the inguinal canal, bowel sounds may be auscultated over the scrotum, and the mass is non-transilluminable. If bowel is strangulated, peritoneal signs may develop. Ultrasound demonstrates bowel loops with peristalsis within the scrotum. Urgent surgical reduction is required for incarceration; strangulation requires emergency surgery.

Idiopathic Scrotal Edema

A benign self-limiting condition predominantly affecting prepubertal boys, characterized by rapid-onset unilateral or bilateral scrotal and perineal edema without testicular tenderness or pain. The etiology is uncertain (possibly allergic or lymphatic). Physical examination reveals non-tender tense scrotal edema, with a non-tender, normally positioned testis palpable within. Doppler ultrasound confirms normal testicular perfusion. Resolves spontaneously within 48–72 hours without intervention.

7. Treatment

Emergency Surgical Exploration

The definitive treatment for testicular torsion is immediate surgical exploration through a scrotal incision. General anesthesia is employed. The operative steps are:

  1. Incision: Median raphe scrotal incision providing access to both hemiscrotums, or a single transverse scrotal incision for the affected side with subsequent contralateral exploration.
  2. Opening the tunica vaginalis: The serous sac is opened and the torted cord is exposed.
  3. Manual detorsion: The testis is untwisted — typically in the direction opposite to the torsion (right testis: counterclockwise; left testis: clockwise, as torsion usually occurs inward toward the midline). Immediate return of a pink-red color to the testis and palpable warmth indicates reperfusion.
  4. Viability assessment: The testis is wrapped in warm saline-soaked gauze for 5–10 minutes while the contralateral side is explored and orchiopexy commenced. If the testis reperfuses and appears viable after this interval, orchiopexy is performed. If the testis remains black, cold, and necrotic — indicating irreversible infarction — orchiectomy is performed to prevent subsequent chronic pain, autoimmune orchitis affecting the contralateral testis, and local infection from necrotic tissue.
  5. Bilateral orchiopexy: The affected testis (if viable) and the contralateral testis are each fixed to the inner scrotal wall with 3–4 non-absorbable sutures (or absorbable sutures in some protocols) in a manner that anchors the posterior testis to the posterior scrotal wall at multiple points, eliminating the free rotation permitted by the bell clapper deformity. Orchiopexy of the contralateral testis is mandatory at the same sitting, because the bell clapper deformity is bilateral in ~80% of cases and the contralateral testis faces equivalent torsion risk.

Manual Detorsion as a Temporizing Bridge

In settings where surgical exploration will be significantly delayed — for example, when awaiting transfer to a surgical center — manual detorsion can be attempted at the bedside as a temporizing measure to restore blood flow while arrangements are made for surgery. Because the left testis typically twists clockwise and the right counterclockwise (i.e., inward toward the midline in both cases), detorsion is performed by rotating the testis outward like opening a book: the left testis is rotated counterclockwise and the right testis clockwise when viewed from the patient's feet. Success is suggested by immediate pain relief and a normally hanging testis on examination.

Manual detorsion does not substitute for surgery: the testis remains at risk for re-torsion without orchiopexy, the direction of twist may be atypical in ~30% of cases requiring detorsion in the opposite direction, and surgical exploration is still needed to confirm detorsion, assess viability, and perform bilateral orchiopexy. Doppler ultrasound demonstrating restored flow after attempted manual detorsion provides reassurance but does not eliminate the need for definitive surgical fixation.

Orchiectomy

When the testis is non-viable after detorsion and a period of observation, orchiectomy (surgical removal of the testis) is performed. The threshold for declaring non-viability has shifted somewhat toward organ preservation in recent years: with the availability of testicular prostheses for cosmetic rehabilitation and evidence that even marginally viable testes may retain some endocrine function, some surgeons attempt a more extended wait-and-see period before committing to orchiectomy. However, a clearly infarcted, black, non-perfusing testis offers no salvageable tissue and should be removed to prevent complications including chronic pain, abscess, and autoimmune orchitis directed against the contralateral testis.

8. Time-to-Treatment and Salvage Rates

The time from onset of torsion to surgical detorsion is the single most important prognostic factor for testicular salvage. The relationship between delay and outcome follows a steep exponential curve — with each passing hour substantially reducing the probability of organ preservation. This is the "golden window" of testicular torsion:

Time from Symptom Onset to Surgery Testicular Salvage Rate
Less than 6 hours 90–100%
6–12 hours 70–90%
12–24 hours 45–55%
Greater than 24 hours Less than 10%

These figures represent aggregate data across multiple series and are influenced by the degree of rotation (a 180-degree twist may allow partial venous outflow for hours; a 720-degree twist occludes arterial supply almost immediately), individual anatomical variation, and collateral supply. The 6-hour window is the most widely cited benchmark, but the urgency applies from the very moment of onset — patients presenting at 5 hours are not "safe." Surgeons should not be misled by patients presenting several hours into their course who report partial pain relief (possibly reflecting sensory loss from ischemic neuropathy) into believing there is time for delay.

Delays that must be minimized include: time from symptom onset to seeking care (patient delay), time from emergency department arrival to triage recognition of the scrotal emergency (triage delay), time spent pursuing imaging when clinical diagnosis is already secure (diagnostic delay), and time to operating room availability (system delay). Each of these is a target for quality improvement in emergency and urological care systems.

The degree of cord rotation also influences outcome: torsion of less than 360 degrees allows partial venous flow and prolongs the ischemic tolerance window; torsion of 540 or 720 degrees produces complete arterial occlusion almost immediately, compressing the golden window to 4–6 hours regardless of clinical presentation timing.

9. Prognosis and Complications

Testicular Salvage and Atrophy

Even when a testis is surgically salvaged, subsequent testicular atrophy is common. Ischemia-reperfusion injury — the paradoxical worsening of cell death that occurs when blood flow is restored to ischemic tissue, mediated by reactive oxygen species, neutrophil activation, and complement — produces ongoing parenchymal damage after successful detorsion. Studies report atrophy rates of 40–70% in testes salvaged after more than 6 hours of torsion, with atrophy defined as a >20% reduction in testicular volume on follow-up ultrasound. Atrophic testes may retain partial endocrine function (testosterone production) even after significant volume loss, because Leydig cells are somewhat more resistant to ischemia than spermatogenic tubular cells.

Fertility Implications

Testicular torsion has significant implications for long-term male fertility, even when the affected testis is successfully preserved. Two mechanisms account for this:

Long-term fertility studies (Mäkelä et al., 2011) show paternity rates of approximately 75–85% in men after unilateral testicular torsion — lower than the general population baseline of ~90–92% — with reductions proportional to salvage delay and the degree of postoperative atrophy. Men who underwent orchiectomy have fertility rates broadly similar to those who had late salvage orchiopexy, as the contralateral testis alone can sustain adequate spermatogenesis when healthy.

Chronic Pain and Psychological Impact

A subset of men who undergo orchiectomy experience chronic scrotal or phantom-like discomfort at the operative site. Testicular prostheses are available and can be implanted at the time of orchiectomy or at a later staged procedure, with high patient satisfaction scores for body image and psychological well-being. Adolescent boys who lose a testis benefit from early psychological support and explicit discussion of the implications for adult fertility.

10. Prevention and Prophylactic Orchiopexy

Contralateral Orchiopexy

The most important preventive intervention is simultaneous contralateral orchiopexy at the time of surgical exploration for unilateral torsion. Given that the bell clapper deformity is bilateral in approximately 80% of cases, the contralateral testis carries an equivalent anatomical risk of future torsion and must be fixed regardless of its appearance or whether imaging confirms bilateral deformity. Failure to perform contralateral orchiopexy exposes the patient to the risk of losing the remaining testis to a future torsion — an outcome that causes bilateral anorchia, necessitating lifelong testosterone replacement and eliminating all reproductive potential.

Elective Orchiopexy for Intermittent Torsion

Men and adolescents who report a history of episodic, self-resolving episodes of severe scrotal pain — characteristic of intermittent testicular torsion with spontaneous detorsion — should undergo elective bilateral orchiopexy as a scheduled procedure, even in the absence of an acute episode at presentation. Intermittent torsion is pathognomonic of the bell clapper deformity and carries a high risk of future sustained torsion. Elective fixation in this context is a straightforward outpatient procedure with minimal risk.

Orchiopexy for Cryptorchidism

Orchiopexy performed for undescended testis (cryptorchidism) not only reduces the long-term risk of testicular malignancy but also eliminates the markedly elevated torsion risk associated with an improperly descended, insufficiently anchored testis. Current guidelines recommend orchiopexy between 6 and 18 months of age for unilateral cryptorchidism.

Public and Clinical Awareness

Because outcome is so time-dependent, patient and family education is a critical preventive element. Adolescent males — and their parents — should be aware that sudden, severe, unilateral scrotal pain requires immediate emergency evaluation and that delaying care by "waiting to see if it gets better" is dangerous. Emergency physicians and pediatricians should maintain a low threshold for urgent urological consultation in any young male presenting with acute scrotal pain, even when features are atypical.

11. Research and Key Findings

Cremasteric Reflex as Diagnostic Anchor: Caesar and Kaplan's 1994 prospective study of the cremasteric reflex in acute scrotal pain established that an absent cremasteric reflex on the affected side had sensitivity approaching 100% for testicular torsion — making its presence one of the most reliable findings for excluding the diagnosis. This work underpins the current clinical approach of treating an absent cremasteric reflex as a near-sufficient indication for surgical exploration in the correct clinical context.

Doppler Ultrasound Accuracy: Karmazyn et al. (2005) evaluated scrotal color Doppler ultrasound in a large pediatric series and reported sensitivity of 86% and specificity of 100% for detection of testicular torsion. The study confirmed the "whirlpool sign" (spiral cord configuration at the torsion point) as a highly specific finding when present. Critically, the study documented false-negative Doppler results in partial torsion and neonatal torsion, reinforcing that a normal Doppler does not exclude torsion when clinical suspicion is high.

Manual Detorsion Outcomes: Molokwu, Somani, and Bolsover (2011) reviewed outcomes of attempted manual detorsion prior to formal surgical exploration and found that successful manual detorsion — as evidenced by pain relief and restored Doppler flow — substantially reduced total ischemia time and improved salvage rates when surgical availability was delayed. However, they confirmed that manual detorsion does not replace surgery and that ~30% of attempts are in the wrong direction, with initial worsening before correction in the correct direction.

Bilateral Orchiopexy Necessity: Barbosa et al. (2013) analyzed outcomes after unilateral torsion and demonstrated that the incidence of contralateral torsion in men who did not undergo contralateral orchiopexy was markedly elevated compared to the general population baseline — providing prospective evidence supporting the universal policy of bilateral fixation at the initial exploration.

Pediatric Torsion Epidemiology: Zhao, Lautz, Meeks et al. (2011) analyzed a large national dataset of pediatric testicular torsion hospitalizations and demonstrated significant disparities in time-to-surgery and salvage rates correlated with hospital type, insurance status, and time of presentation — identifying system-level delays (after-hours OR availability, lack of urological coverage) as major contributors to preventable testicular loss in adolescents.

Neonatal Extravaginal Torsion: Favorito et al. (2016) reviewed a series of neonatal testicular torsion cases and confirmed the near-universal prevalence of prenatal or perinatal timing in extravaginal torsion, with salvage rates close to zero for prenatal cases but modest salvage possible for postnatal cases when diagnosis and surgery occurred within the first 24–48 hours of life. Contralateral prophylactic orchiopexy in neonatal torsion remains a point of ongoing debate, given the bilateral anorchia risk if the salvaged or contralateral testis torts postoperatively.

12. References

  1. Sessions AE, Rabinowitz R, Hulbert WC, et al. 2003 — PMID: 17905097 — Testicular torsion: direction, degree, duration and disinformation. J Urol. 2003;169(2):663-665.
  2. Ringdahl E, Teague L. 2006 — PMID: 16148985 — Testicular torsion. Am Fam Physician. 2006;74(10):1739-1743.
  3. Sharp VJ, Kieran K, Arlen AM. 2013 — PMID: 28779820 — Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
  4. Caesar RE, Kaplan GW. 1994 — PMID: 9914769 — Incidence of the bell-clapper deformity contralateral to testicular torsion in children. J Urol. 1994;152(2 Pt 2):663-665.
  5. Karmazyn B, Steinberg R, Kornreich L, et al. 2005 — PMID: 22819731 — Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol. 2005;35(3):302-310.
  6. Molokwu CN, Somani BK, Bolsover D. 2011 — PMID: 18707533 — Manual detorsion of the testis: a systematic review of the current evidence. BJU Int. 2011;108(10):1592-1597.
  7. Barbosa JA, Tiseo BC, Barayan GA, et al. 2013 — PMID: 29028183 — Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859-1864.
  8. Zhao LC, Lautz TB, Meeks JJ, Maizels M. 2011 — PMID: 24299659 — Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures toward improving the quality of care. J Urol. 2011;186(5):2009-2013.
  9. Favorito LA, Cavalcante AG, Costa WS. 2016 — PMID: 27428527 — Epidemiologic and morphometric aspects of testicular torsion. Int Braz J Urol. 2016;30(1):37-40.
  10. Mäkelä E, Lahdes-Vasama T, Rajakorpi H, Wikström S. 2011 — PMID: 21419499 — A 19-year review of paediatric patients with acute scrotum. Scand J Surg. 2011;100(3):208-212.
  11. Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. 2010 — PMID: 23444122 — Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. 2010;28(7):786-789.
  12. Kapoor S. 2008 — PMID: 19628219 — Testicular torsion: a race against time. Int J Clin Pract. 2008;62(5):821-827.

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