First, the most important takeaway: If you have sudden, severe pain in your testicle or scrotum, do not wait—go straight to the emergency room.
Later in this article, we will explain the causes, how it is diagnosed, and what surgery involves. However, if you are in pain right now, or if your child wakes up crying with pain down there in the middle of the night, head out the door now and read the rest on the way.
What Is Testicular Torsion?
The testicles hang inside the scrotum, suspended from above by the spermatic cord, which contains the blood vessels, nerves, and vas deferens supplying the testicle. Normally, the testicle is anchored by surrounding tissue and cannot twist freely.
Some people are born with weaker anchoring tissue, allowing the testicle to swing inside the scrotum like the clapper of a bell—a condition known medically as bell clapper deformity. If the testicle rotates around the spermatic cord, the cord twists like a wrung-out towel, cutting off blood flow. This is testicular torsion.
When blood flow is cut off, the testicle begins to suffer from lack of blood (ischemia). If this goes on too long, the testicle may suffer tissue death (necrosis) and cannot be saved.
Depending on where the twisting occurs, doctors classify it into two types:
- Intravaginal torsion: The testicle twists inside its outer covering (the tunica vaginalis). This is most common during puberty and is usually related to a bell clapper deformity.
- Extravaginal torsion: The testicle and the tunica vaginalis twist together as a whole. This occurs mainly in newborns because the testicle has recently descended into the scrotum and is not yet fully anchored.
Who Is at Risk for Testicular Torsion?
It can happen to males of any age, but it is most common during two main periods:
- Adolescent boys: Cleveland Clinic notes that ages 12 to 18 are at higher risk. Because the testicles grow rapidly during puberty, inadequate anchoring is more likely to cause problems.
- Newborns and infants: Babies cannot tell you they are in pain; they often just cry inconsolably, refuse to feed, or have a scrotum that looks swollen or discolored.
In addition, people who have had torsion before or have a family history of it are at higher risk.
Many people assume it is caused by sports or jumping. In reality, that is not always the case—it can happen while sitting or sleeping, so waking up in severe pain in the middle of the night is not uncommon.
What Are the Symptoms of Testicular Torsion?
- Sudden, severe pain in one testicle or one side of the scrotum, often becoming unbearable within minutes
- Swelling of the scrotum, with skin that may look red or dark purple
- The painful testicle appears to sit higher than normal or at an unusual angle
- Nausea and vomiting, sometimes accompanied by pain in the lower abdomen or groin
- Pain severe enough to make walking or standing difficult
One important reminder: If the pain goes away on its own after a while, it does not mean everything is fine. The testicle may have twisted and untwisted on its own (intermittent torsion), and it can easily twist again in the future. You should still see a urologist as soon as possible.
Also, teenagers are often too embarrassed to mention genital pain and may only say their stomach hurts. If parents notice a child has abdominal pain along with vomiting, be sure to ask if it hurts down there too.
How Do You Tell Testicular Torsion Apart from Epididymitis?
Both conditions cause the scrotum to become red, swollen, and painful, looking very similar from the outside—even doctors cannot always tell them apart by visual exam alone. The general differences are listed below, but this is for reference only and must not be used to decide on your own whether to go to the hospital:
| Testicular Torsion | Epididymitis | |
|---|---|---|
| Onset of pain | Sudden and severe | Usually builds up gradually over hours to days |
| Typical age | More common in adolescents and newborns | More common in adult men, though it can occur in children |
| Fever and urinary discomfort | Less common | More common; a urine test may show signs of inflammation |
| Blood flow on ultrasound | Decreased or nearly absent | Usually increased |
| Treatment | Emergency surgery | Usually treated with medication and rest |
Another common cause of sudden scrotal pain in adolescents is torsion of the appendix testis. The appendix testis is a small remnant of tissue from embryonic development; when it twists, it is also very painful, though it usually does not threaten the testicle itself. However, it is impossible to tell the difference at home, so always let a doctor evaluate it.
For more details on epididymitis, see ‘What Is Epididymitis?’; for other causes of testicle pain, see ‘What Causes Testicle Pain?’.
Why Must Testicular Torsion Be Treated Immediately?
Because the length of time the testicle goes without blood flow almost directly determines whether it can be saved.
MedlinePlus notes that if surgery is performed within 6 hours of symptom onset, most testicles can be saved; if blood flow is reduced for more than 6 hours, the likelihood of needing to remove the testicle increases. Cleveland Clinic also states that a testicle can survive for only about 6 hours without blood flow.
To be honest, however, 6 hours is not a guaranteed safe window. MedlinePlus also warns that a testicle can still lose function even if torsion lasts less than 6 hours. So our advice is simple: Do not watch the clock—go to the ER as soon as the pain starts.
Common reasons for delay include trying to sleep it off, feeling too embarrassed to tell family members, waiting in line at a local clinic first, or driving yourself to the hospital. A better approach is to have a family member or friend drive you directly to the emergency room of a hospital with urological or surgical capabilities. The UK NHS also advises against driving yourself to the emergency room.
How Is Testicular Torsion Diagnosed?
- Medical history and physical exam: The doctor will ask when the pain started and what it feels like, examine the position, swelling, and tenderness of the testicle, and check physical signs such as the cremasteric reflex.
- Scrotal Doppler ultrasound: This is the most commonly used test to evaluate blood flow inside the testicle. In testicular torsion, blood flow is typically reduced or undetectable; in inflammation, blood flow is often increased.
- Urine test: Helps check for infection to distinguish torsion from epididymitis.
Keep in mind that ultrasound is not infallible. Mayo Clinic notes that ultrasound does not always detect reduced blood flow, so it cannot be relied upon alone to rule out testicular torsion. If the doctor has a strong clinical suspicion, they may proceed directly to scrotal exploration without waiting for test results. This is not overtreatment—it is because the cost of waiting is too high.
How Is Testicular Torsion Treated?
Surgery: Detorsion and Orchiopexy
Testicular torsion does not heal on its own. The primary treatment is surgery, specifically scrotal exploration:
1. Make a small incision in the scrotum (or sometimes the groin)
2. Untwist the twisted spermatic cord to restore blood flow
3. Observe the color and blood flow of the testicle to determine whether it can be saved
4. Use sutures to anchor the testicle to the inner wall of the scrotum (orchiopexy) to prevent future torsion
The other testicle is usually anchored at the same time. Because the bell clapper deformity that causes torsion is often present on both sides, the unaffected testicle is also at risk of twisting in the future.
If the Testicle Has Suffered Tissue Death
If blood flow has been cut off for too long and the testicle is no longer viable, the doctor may need to perform an orchiectomy (surgical removal of the testicle) to prevent complications such as infection. After one testicle is removed, the remaining testicle can still maintain normal hormone production and fertility, though Cleveland Clinic notes that a drop in sperm count can sometimes occur after torsion, which you can discuss and monitor with your doctor. If you are concerned about appearance, you can also talk with your doctor about placing a prosthetic testicle.
Can I Try to Untwist It Myself at Home?
No. Cleveland Clinic explicitly warns against trying to untwist the testicle yourself, as this can make the torsion worse. In the emergency room, a doctor may sometimes attempt manual detorsion first, but even if that succeeds, orchiopexy surgery is still typically needed afterward.
What Should You Do If Sudden Testicle Pain Happens at Home?
1. Go to the emergency room immediately, choosing a hospital with urology or surgery services capable of performing emergency surgery.
2. Have someone drive you or call an ambulance—do not drive yourself.
3. Do not apply a heating pad or ice pack and go back to sleep, and do not try to massage or twist the testicle yourself.
4. If it is a child, parents should note roughly when the pain or crying started and let the doctor know upon arrival.
Frequently Asked Questions (FAQ) About Testicular Torsion
Yes. The testicle may have twisted and untwisted on its own, and it could twist again in the future. You should see a urologist as soon as possible to evaluate whether preventive orchiopexy surgery is needed.
That is not recommended. Treating testicular torsion is a race against time—the longer the delay, the harder it is to save the testicle. Even if it happens in the middle of the night, go straight to the emergency room rather than waiting for a clinic to open.
There is no reliable way to tell them apart at home. Both cause redness, swelling, and pain, and even doctors often need a scrotal Doppler ultrasound or scrotal exploration to be certain. Treat any sudden, severe testicle pain as an emergency first.
No. While it is most common in adolescents and newborns, it can also happen in adult men. Since babies cannot say they are in pain, seek medical attention promptly if an infant cries inconsolably or has a swollen or discolored scrotum.
If the testicle is untwisted in time and saved, function is preserved in most cases; even if one testicle is removed (orchiectomy), the remaining testicle is usually able to maintain hormone levels and fertility. However, because a lower sperm count can sometimes occur after torsion, anyone planning to have children can discuss follow-up testing with their doctor.
A congenital bell clapper deformity cannot be prevented ahead of time. What you can do is recognize the warning sign: seek emergency medical care immediately for sudden, severe testicle pain. For someone who has already experienced torsion once, both testicles are typically anchored during surgery (orchiopexy) to reduce the chance of recurrence.
Medical References
- MedlinePlus (U.S. National Library of Medicine): Testicular torsion
- Cleveland Clinic: Testicular Torsion
- NHS: Testicle pain
- StatPearls (NCBI Bookshelf): Testicular Torsion
- Mayo Clinic: Testicular torsion – Diagnosis and treatment
Further Reading
Advice from a Urologist
Testicular torsion is uncommon, but it is one of the few urological conditions that truly cannot wait. It is far better to make a trip to the emergency room and find out it is just inflammation than to wait at home until the testicle cannot be saved. If you have a teenage boy at home, let him know ahead of time: if he ever gets sudden, severe pain down there, do not feel embarrassed—speak up right away.
This article is for health education purposes only and does not replace a doctor’s diagnosis; please seek medical attention if you feel unwell.
