Dear Dr G,

I am a young chap studying engineering as a second-year student.

I am rather worried about intermittent pain in my left testicle.

It all started when I started playing football for the varsity team a year ago.

During the match, I started experiencing this excruciating pain in my left scrotum.

I was taken off the pitch and the coach told me I had twisted testicle.

He initially offered to “untwist” it, however I was too embarrassed and asked to be taken to a hospital‘s Accident and Emergency unit instead.

Thankfully, when I reached the hospital, the pain subsided.

The doctors confirmed the source of the pain was the twisted testicle.

He told me it is a medical emergency and would likely happen to me again in my youth.

Indeed, the same pain happened last week, and the testicle “untwisted” itself again when I reached the hospital.

The doctors suggested I do an elective operation to prevent future twisting.

Meanwhile, my football coach reckons the twisting is due to too much masturbation and reckons I should stop it completely.

What exactly is torsion and why would the testicle get twisted at all?

Who exactly is at risk of testicular torsion?

What would be the consequence of testicular torsion?

How will this affect my fertility?

Do you think regular sexual thoughts and masturbation is causing the testicles to twist?

Do you think I should accept the operation to prevent future twisting?

Can you please explain what operation he is referring to and what are the risk?

Thank you again for your help.


Twisted Tim

Testicular torsion occurs when the spermatic cord is twisted, cutting off the blood supply to the gonad. Torsion of the testicle frequently occurs among adolescents. Sixty-five percent of cases present between 12 and 18 years of age. The risk of torsion before the age of 25 is 1 in 4,000 to 1 per 25,0000. Although torsion can affect men at any age, the risk of torsion in adulthood is exceedingly rare. External factors such as cold temperature or testicular trauma are thought to be risk factors associated with torsion.

Young adults with torsion may be awakened by pain in the middle of the night or early in the morning.

Although sexual arousal can induce movement of the testicles, sexual activities such as intercourse or masturbation is not known to cause testicular torsion.

Most young men with testicular torsion have no prior health problems or preceding medical conditions. However, one study highlighted larger testicles are more prone to twisting.

Several congenital anatomical malformations in the testicle are associated with torsion. One of these anomalies is described as “Bell-clapper deformity” which accounts for 90% of all cases. In this condition, rather than being fixed to the posterior wall of the scrotal sac, the testicle together with the excessively long spermatic cord floats freely in the sac. The suspension of the testes within the scrotum increases the risk of spontaneous mechanical twisting.

The degree of blood supply occlusion depends on the duration and severity of torsion.

The blood supply to both testicles is delivered by the spermatic cord from the abdomen resulting in the suspension of the testicles within the scrotal sac. The sudden twist of the testicle is due to active movements of one or both testicles. Such movements are believed to be more active in youth, therefore torsion predominantly occurs in children, adolescents, and young adults. Without prior warnings, twisted testicles often present with sudden, severe testicular pain. The affected testicle is often stuck in the upper scrotum. The pain is often described as excruciating, associated with abdominal cramp, nausea, and vomiting.

When testicular torsion occurs in newborns, the pain is absent and instead the scrotum may become discolored and eventually shrinks. Therefore, it is often believed neonatal torsion can cause the vanishing of testis, resulting in an infant being born with only one testicle.

Prompt diagnosis of torsion is made based on the presenting symptoms. An ultrasound may be useful when the diagnosis is unclear, however this may delay the timing of the operation.

The treatment of testicular torsion is physically untwisting the testicle, often achieved by surgery. The operation to untwist the testicle is usually followed by orchidospexy.

Such operation is usually done on both testicles, with fixation to the scrotal wall preventing future twisting. When the correction is done within six hours, ninety percent of the affected testicles can be saved. At 12 hours, the survival is reduced to 50%. Sadly, only 10% of testicles are salvageable after 24 hours.

The long-term impact of testicular torsion on is not fully understood. However, the decrease in blood flow resulting in ischemia in testicular torsion is known to result in abnormal sperm function on semen analysis.

Despite the negative impact on sperm quality, testicular torsion does not seem to affect the long-term impact of childbearing in affected men when salvaged early. The long-term psychological impact of men suffering from torsion into their adulthood is unclear, however small studies revealed minimal long-term negative psycho-sexual impact in the future.

Testicular torsion is one of the few urological emergencies requiring precise diagnosis from the medical history, followed by prompt intervention to restore blood supply.

As the condition predominantly happens in adolescent and young adults, the embarrassment and stigma deter affected men to seek medical help.

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