Testicular torsion is one of the most concerning diagnoses we can see in the emergency department, but a lot of the things we have come to accept as dogma regarding this dangerous diagnosis aren’t always as straightforward as board exams would have you believe!

Dogma #1: Thunderclap Onset: Onset can be insidious, and may present with only vague testicular/abdominal pain, depending on degree of ischemia.

Dogma #2: Time is Testicle: the 6 hours from onset of pain to the testicle becoming unsalvageable is extremely variable, again depending on degree of ischemia. There are case reports of testicles remaining salvageable DAYS after onset of ischemia, so don’t delay care just because you think they’re outside the window!

Dogma #3: Cremasteric Reflex: one study has shown that 40% of males with testicular torsion still have their reflex even after they’ve torsed. In addition, one third of males not have even have a cremasteric reflex at baseline.

Dogma #4: Testicles Always Torse Medially: Torsion is in the medial direction only two thirds of the time. If you don’t get a response by “opening the book” and rotating the testicle laterally, try the other direction.


Mellick, L. Torsion of the testicle; it is time to stop tossing the dice. Pediatr Emerg Care. 2012 Jan PMID: 22217895

Mason, Jessica and Bob Jones. Testicular Torsion. EMRAP. 2016 Sept. https://www.emrap.org/episode/thereturn/testicular