Testicular Torsion on PoCUS: Recognizing a Time-Critical Emergency

Sudden unilateral scrotal pain? Think torsion.

Testicular torsion occurs when the spermatic cord twists, progressively obstructing venous drainage and arterial blood flow to the testis. It requires prompt surgical treatment because delays can lead to testicular ischemia and loss.

Clinical features that should raise concern include:

1. Sudden, severe unilateral scrotal pain
2. Nausea or vomiting
3. A high-riding or horizontally positioned testis
4. Testicular swelling and tenderness
5. An absent cremasteric reflex

Scanning Technique

Use a high-frequency linear transducer and scan both testes in longitudinal and transverse planes.

Start with the unaffected side to optimize the Doppler settings and establish a normal comparison. A transverse “buddy view,” showing both testes on the same image, can help identify differences in size, echogenicity, and perfusion.

Assess the testicular tissue with grayscale imaging, then evaluate vascularity using colour or power Doppler. Doppler settings should be adjusted for low-velocity flow to avoid falsely interpreting a viable testis as avascular.

Key Ultrasound Findings

Findings that may support testicular torsion include:

1. Reduced or absent intratesticular blood flow compared with the opposite side
2. A twisted spermatic cord, known as the whirlpool sign
3. An enlarged, hypoechoic, or heterogeneous testis
4. A reactive hydrocele
5. Scrotal wall thickening

The whirlpool sign directly demonstrates twisting of the spermatic cord and is an important sonographic finding of torsion, as highlighted by Sonoray.

Preserved Flow Does Not Exclude Torsion

Early, partial, or intermittent torsion may still demonstrate arterial flow on Doppler imaging. Comparing both sides and assessing the spermatic cord are therefore essential. A normal-appearing Doppler examination should not override a strongly suspicious clinical presentation. European urology guidance notes that persistent arterial flow does not exclude torsion and that ultrasound must not create an unnecessary delay in emergency treatment.

Ultrasound and duplex Doppler are appropriate imaging examinations for acute scrotal pain when imaging is needed. However, when clinical suspicion is high, immediate urologic consultation and surgical evaluation take priority.

Compare both testes.

Look for the cord twist.

Never let imaging delay urgent treatment.