The male scrotum is the sac-like tissue structure behind the penis where the fertility-determining testes and their accessory structures are housed. Normally, blood flow to the testicles is continuous through the spermatic cords. If the testicle rotates abnormally, it can twist the attached spermatic cord and block the blood supply to the testicle. This condition accounts for 26% of scrotal emergencies, and although it can occur at any age, it is most common in boys between the ages of 12-17. When torsion occurs, pediatrics and adolescents sometimes have scrotal pain that reflects to the abdomen, so it is important to check the scrotum when lower abdominal pain occurs in children of this age. If it is not detected and treated in time, it can lead to testicular necrosis and surgical removal. Since the consequences of testicular torsion are so severe, timely and accurate recognition is very important. The patient will experience severe pain within the scrotum, sometimes manifesting as abdominal pain. Subsequently, an inflammatory reaction occurs due to the blockage of blood flow and the scrotum becomes enlarged and red. The testicles are connected to the internal organs and some people experience nausea and vomiting. In some rare cases, a torsioned testicle will reset itself without surgical intervention. But if you or someone you see is in severe pain and has an enlarged scrotum, seek medical attention immediately. So why would a testicle torsion happen when it’s fine? Unfortunately, the exact reason why torsion occurs is still inconclusive. Some believe it is congenital, as even very young children have torsion. It also occurs during excessive exercise and prolonged exposure to cold, but some occur during sleep. Who is at high risk for testicular torsion? Teenagers aged 12-17 have the highest chance. Another is those who have similar occurrences in their family. If the torsion has occurred and then reset itself, the chances of it happening again are also high. How is testicular torsion determined? An examination by a medical professional is usually enough to determine this, and will also explore for scrotal pain or swelling, and a scrotal ultrasound Doppler ultrasound pattern can also show blood flow and the severity of testicular ischemia. However, surgical exploration should not delay the decision by imaging. Illustration: RT right testis – good blood flow; LT left testis – volume increase and lack of blood flow What to do in case of testicular torsion? Only in a very small number of patients will the surgeon attempt a manual testicular repositioning, which is not recommended in patients in whom pain has occurred for more than 6 hours. But in the vast majority of patients the management is very clear and the only way is surgical exploration! Surgical treatment is as follows: after anesthesia, the doctor will make a small incision in the scrotum, then take out the contents and gently reset the twisted spermatic cord to restore the blood supply. If the testicle is okay in terms of viability, after the return it will be secured with stitches to the scrotum on both sides of the testicle to prevent re-twisting from occurring. In most cases, a similar fixation is made to the opposite healthy testicle. Illustration: left – during torsion; right – after reversal Note that testicular torsion is a very time-intensive procedure, and recovery of the testicle is not possible until 6-8 hours have elapsed. Beyond this time frame there is no guarantee that the testicle can be saved. If the testicle is found to be inactive at the time of surgery, the surgeon will remove it. Once a testicle is lost unilaterally it means that it is less likely that you will have children in the future. Testicular torsion, described above, is a urological emergency that carries the risk of not being detected and treated in time because it occurs more often in children and there are certain barriers to communication. A reminder to take it seriously, especially as a parent!