Acute, intense pain on one side of the scrotum indicates a twisted stalk (torsio) of the testis. This seems to happen to one man in 4,000 annually. The testicles do not lie loose in the scrotum: they are attached to it by a wide band which prevents the testicle from turning vertically on its axis. There are some men, mostly aged between ten and 30, in whom the band is too long and often too narrow. One day they may have the unfortunate experience of one of their testicles starting to turn: this is impossible to mistake, since the victim feels sudden intense pain in the scrotum, spilling over into the groin. The scrotum becomes red or purple, and patient is often nauseous. In a physical examination the observant doctor will notice in a case of torsion the cremaster reflex, the retraction of the testicles in the direction of the groin when the inside of the thigh is stroked. It can happen that a torsion disappears spontaneously after a short time, and with it the pain. Even then it is advisable to consult a doctor, since the phenomenon will undoubtedly recur one day, and it’s doubtful whether expert help will be on hand.
The fact is that torsio testis can have unpleasant consequences. As a result of the twisting of the testicle pressure is put on the veins and the artery. The flow of blood is interrupted and, if the situation continues for more than a few hours, the tissue in the testicle will die off for want of oxygen. The speed with which that happens depends on the extent to which the testicle has turned on its own axis. Sometimes it may have turned 360 degrees, in which case the process will be very rapid. The sperm-producing cells particularly are sensitive to a lack of oxygen, while those that make testosterone, the Leydig cells, survive longer. If a twisted testicle is untwisted within about four hours there need be no further repercussions. This need not, by the way, require an operation; an expert doctor may in the first instance attempt to solve the problem manually. He or she should keep in mind the image of a heavy book, say a massive King James Bible, which has to be opened — outwards.
Occasionally a torsio testis is not recognized and the pain and swelling are attributed to an inflammation of the epididymis, so subsequently a completely wrong treatment is applied, usually with antibiotics. This results in the completely unnecessary loss of an important organ. When in doubt, the best thing to do is to operate immediately, possibly after a duplex echograph. In this kind of operation the other testicle is immediately included, that is stabilized, to ensure that the problem will never be repeated on that side.