Pediatric emergency medicine trisk 1174 1174

FIGURE 61.2 Torsion testis. Abnormality of testicular fixation—bell-clapper deformity—
permits torsion of spermatic vessels with subsequent infarction of the gonad. Epid., epididymis.

Torsion results from an inadequate fixation of the testis to the intrascrotal
subcutaneous tissue ( Fig. 61.2 ), resulting in the “bell-clapper” deformity. The
testis, which hangs more freely within the tunica vaginalis in this deformity, may
rotate, producing intravaginal torsion of the spermatic cord, venous engorgement
of the testis, and subsequent arterial infarction ( Fig. 61.3 ).
The sudden onset of severe scrotal pain and tenderness, often with radiation to
the abdomen, and associated nausea and vomiting is typical. They may be
associated with sports activity or mild testicular trauma that is perceived by the
patient as the cause of pain. Prior episodes of similar pain that resolved may
suggest intermittent torsion and spontaneous detorsion.
With torsion, the testis is acutely swollen, diffusely tender, and usually lies
higher (“horizontal lie”) in the scrotum than the contralateral testis. There may be
overlying erythema of the scrotal skin. The cremasteric reflex (retraction of the
testis with stroking of the inner thigh) is usually absent with testicular torsion, but
may be present in early or incomplete torsion. The cremasteric reflex may be
absent in some boys without torsion, usually less than 6 months of age. Since pain