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Prof. Dr. Ali Avanoğlu
Undescended Testicle • Diagnosis and evaluation

Testicular Torsion: Sudden Pain in an Undescended Testicle Is an Emergency

Testicular torsion (the testicle twisting around its own blood vessels) is a true surgical emergency that cuts off the testicle's blood supply within hours. In children with an undescended or ascending testicle, the pain may be felt in the groin or abdomen rather than the scrotum, which is why diagnosis can be delayed. The rule is clear: don't wait out sudden, severe pain — go to the nearest emergency department.

Who this is forFamilies facing sudden groin, abdominal, or scrotal pain in a child with an undescended or ascending testicle
Reading≈6 min
ByProf. Dr. Ali AvanoğluUpdated
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in the inguinal canal
01 · What is torsion, and why is it more common in an undescended testicle?02 · Which symptoms are an emergency?03 · Why do the hours matter so much?04 · What happens in the emergency department and the operating room?05 · What can be done to reduce the risk?
In brief5 madde
  • What is torsion, and why is it more common in an undescended testicle?: The testicle hangs into the scrotum from the spermatic cord, which carries the vessels that supply it.
  • Which symptoms are an emergency?: Torsion usually starts suddenly, sometimes waking the child from sleep.
  • Why do the hours matter so much?: In torsion, the likelihood of saving the testicle is directly related to the time between the onset of pain and surgery.
  • What happens in the emergency department and the operating room?: In the emergency department, the physician examines the groin and scrotum, checks the cremasteric reflex, and calls in pediatric urology or pediatric surgery if…
  • What can be done to reduce the risk?: The most effective way to reduce the risk of torsion is timely descent and fixation of the undescended testicle into the scrotum; orchiopexy markedly lowers this risk.
01

What is torsion, and why is it more common in an undescended testicle?

The testicle hangs into the scrotum from the spermatic cord, which carries the vessels that supply it. When this cord twists around itself, blood flow out of the testicle is cut off first, then blood flow into it; the tissue begins to suffer damage within hours. This is called testicular torsion, and its only treatment is prompt surgery to untwist it without losing time.

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  • An undescended testicle is one that isn't fixed in the scrotum and sits freely in the inguinal canal or the abdomen; because its attachment via the gubernaculum (the connective tissue that guides the testicle into the scrotum) is weaker, it's more prone to twisting. The literature reports a higher risk of torsion in an undescended testicle than in a scrotal one; this risk becomes even more pronounced as the testicle grows during adolescence and adulthood.
  • Torsion in a scrotal testicle announces itself with pain right away; in an undescended testicle, however, the location of the pain is misleading. It starts as groin or lower abdominal pain and can be mistaken for appendicitis, a strangulated inguinal hernia, or simple abdominal pain. Every emergency physician should think of torsion when an empty half of the scrotum is seen — and as a parent, it's important for you to point this out.
02

Which symptoms are an emergency?

Torsion usually starts suddenly, sometimes waking the child from sleep. The pain is severe and doesn't pass within hours; in young infants, who can't describe pain in words, the only signs may be inconsolable fussiness, crying, vomiting, and loss of appetite.

  • Sudden, severe pain in the groin, lower abdomen, or scrotum
  • A firm, tender, palpable swelling in the groin or scrotum, with redness or bruising of the overlying skin
  • Nausea, vomiting, restlessness; inconsolable crying in infants
  • Pain diagnosed as 'abdominal pain' that doesn't resolve, in a child with a history of undescended or ascending testicle
  • Pain that eases and then returns
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  • If one or more of the following signs is present, waiting at home to observe is not the right approach — go to the nearest emergency department.
  • The pain easing on its own is not a reassuring sign: the testicle may have partly twisted and then untwisted again (intermittent torsion), and the risk of twisting again remains. This picture also requires emergency evaluation.
03

Why do the hours matter so much?

In torsion, the likelihood of saving the testicle is directly related to the time between the onset of pain and surgery. The literature reports that the large majority of testicles operated on within roughly the first six hours are saved, that this rate drops rapidly as time passes, and that the testicle is usually lost in cases beyond about 24 hours.

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  • For this reason, none of the approaches 'let's wait until morning,' 'let's give pain medicine and see,' or 'let's get an ultrasound first' are correct. Ultrasound (Doppler) can be helpful when torsion is suspected, but surgery is never delayed for it; if clinical suspicion is strong enough, the child goes straight to the operating room.
  • Delayed diagnosis is more common in an undescended testicle than in a scrotal one, because the location of the pain is misleading and torsion isn't the first diagnosis that comes to mind. This is exactly why families of children with an undescended testicle need to know this information ahead of time.
04

What happens in the emergency department and the operating room?

In the emergency department, the physician examines the groin and scrotum, checks the cremasteric reflex, and calls in pediatric urology or pediatric surgery if there's suspicion. Definitive diagnosis and treatment is surgery: the groin is opened, the testicle is exposed, the twisted cord is untwisted, and the testicle's blood flow is observed.

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  • If the testicle is viable, it's brought down to the scrotum and fixed (orchiopexy) in the same session; this way the torsion is treated and the undescended testicle is permanently corrected at the same time. Because the other testicle may also be prone to twisting, it's usually fixed in place during the same session as well. If the testicle's blood supply is too damaged to recover, it must be removed (orchiectomy); this decision is made during surgery, based on the condition of the tissue.
  • Torsion seen in the newborn period is a separate picture: it usually develops before or during birth, is painless, and is noticed as a firm, discolored half of the scrotum. This, too, requires emergency evaluation; protecting the other testicle becomes the priority.
05

What can be done to reduce the risk?

The most effective way to reduce the risk of torsion is timely descent and fixation of the undescended testicle into the scrotum; orchiopexy markedly lowers this risk. This is one of the reasons the guidelines recommend the 6–12-month window. The risk of torsion is also factored in when deciding on surgery for a testicle that can be brought down in adolescents and adults.

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  • Torsion is very rare in children who've had surgery; however, any new, sudden, severe pain after surgery should still be evaluated urgently. Families of children being followed for a retractile or ascending testicle are given this information at the first examination as well.
  • In this team, examinations, orchiopexy, and emergency surgery are all performed by the same pediatric urologists; however, if torsion is suspected, the first step is not to call your physician — it's to go to the nearest emergency department. You can reach us on the way or from the emergency department; not losing the first hours matters more than anything else.
Undescended Testicle video guide15 short videos, in order
Frequently asked questions
My child has an undescended testicle and sudden abdominal pain has started. Could it be torsion?
Yes, it could. In an undescended testicle, torsion pain is felt in the groin or abdomen rather than the scrotum, and it can be mistaken for other conditions. Don't wait — go to the nearest emergency department, and be sure to tell the physician your child has an undescended testicle.
Should we get an ultrasound first and then go?
No. When torsion is suspected, no time should be lost on imaging; Doppler ultrasound can be helpful in the emergency department, but it should never delay surgery. The first hours are decisive for saving the testicle.
The pain went away on its own; should we still go?
Yes. Pain resolving on its own can mean the testicle untwisted by itself (intermittent torsion); the risk of it twisting again remains. Same-day evaluation is needed, and fixation of the testicle is usually planned.
If a testicle that underwent torsion is saved, will it cause problems later?
A testicle operated on promptly usually keeps its function; however, depending on how much time passed, the testicle may remain smaller. For this reason, testicle size and growth are monitored regularly after torsion; follow-up continues with the same team from childhood into adulthood.
Prof. Dr. Ali Avanoğlu's publications on this topic · 1
  1. Ulman I, Sakalli U, Avanoğlu A, et al. (1996). Serum creatine kinase enzyme levels in the early diagnosis of spermatic cord torsion. Urological research. PubMed ↗
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Related pagesFull index →
BasicsAscending TesticleAn ascending testicle is one that was known to be in the scrotum during infancy but moves out of the scrotum during the growing years and can no longer be brought down by hand. It is usually noticed during the preschool and school years. This is why the fact that "it was normal as a baby" is not, on its own, a guarantee; the testicle's position continues to be checked at examinations through school age.Diagnosis and evaluationExamination and EvaluationUndescended testicle is diagnosed neither by ultrasound nor by blood tests — it is diagnosed through an experienced pediatric urology examination. This page explains exactly what the examination looks for, why how the testicle "behaves" matters so much, and how to prepare for the exam.After surgeryPostoperative PainSome pain is expected after orchiopexy (fixing the testicle in the scrotum) and is controlled with simple pain medication. What matters is being able to tell apart pain that is a natural part of healing from pain that signals a problem. This page explains the expected course of pain, how to manage it, and the warning signs that need urgent attention.BasicsWhat Is an Undescended Testicle?An undescended testicle (cryptorchidism) means the testicle is not in the scrotum at birth, or does not stay there even when it can be moved down by hand. It does not bother the baby or cause pain, but if left untreated, it can affect the testicle's future function. This page explains the basic concepts for families researching the condition for the first time.
Undescended Testicle topic clustersMain treatment page →
Basics 7Diagnosis and evaluation 6Surgery in children 10Special situations 4After surgery 6Adolescents and adults 6Follow-up 3
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