It's Vital to Understand the Risk Factors for Testicular Torsion

Human brains are finely tuned to understand cause and effect. We need that instinct to survive.

Our tree-dwelling ancestors probably noticed very early that if someone went for a midnight stroll on the savanna, screams and the sound of crunching bones soon followed.

So the brain said, "Being down on the ground at night means you get eaten by six different types of predators. Got it."

As much as our brains adore patterns, there are certain events in this world that stubbornly refuse to behave according to cause and effect. One of those is testicular torsion, the twisting of the spermatic cord. That's the bundle of tubes the testicle dangles from in the scrotum, responsible for blood flow and delivering sperm to the ejaculatory duct.

That precious blood supply can be cut off without warning if those tubes get twisted. Even a few hours can mean the death of the testicle. So, yeah, everybody with testicles would probably like to know how and why it happens.

Unfortunately, trying to tease out the causes of testicular torsion can be maddeningly frustrating. Still, we'll look at some possible reasons, what may put some people at higher risk, how you may be able to prevent the worst, and the complications it can cause.

Risk factors for testicular torsion

Again, the causes of torsion are difficult to know. A couple of the risk factors, however, can be identified.

Genetics

Each testicle hangs from the lower abdomen on a spermatic cord, which contains the vas deferens, the tube that carries sperm away from the testicle to the ejaculatory duct. The cord also contains arteries, veins and lymph vessels to keep blood circulating and remove waste. All of this is surrounded by specialized loops of fascia and muscle called the cremaster, which is responsible for raising and lowering the testicle.

For most people, the testicle is attached to the inside of the scrotum, which usually prevents the spermatic cord from getting twisted as it moves around in there. People with an inherited trait called the "bell clapper deformity" don't have that attachment, and the medical community thinks it runs in the family. However, not everyone who has the deformity experiences testicular torsion, and not everyone who gets testicular torsion has the deformity.

"We don't fully understand it," said Amanda North, M.D., the director of urology at the Children's Hospital at Montefiore in the Bronx, New York. "But, yes, if you've had a family history of testicular torsion, you're probably at a higher risk."

Age

Another well-known risk factor is age. While anyone with testicles may experience testicular torsion, about 65 percent of people who do are between 12 and 18 years old, according to Cleveland Clinic.

Theories posit that the rapid growth and flood of hormones that accompany adolescence are involved somehow. But while that's a notable pattern, the medical community still can't say exactly why teens are more vulnerable.

"Nocturnal erections are probably related," North said. "We do see a lot of teenage boys who wake up with a morning erection and a torsion, but we don't really know what the relationship is."

Another theory has to do with the cremaster muscle, the structure wrapped around the spermatic cord that raises and lowers the testicles in response to temperature and other stimuli.

"So there's been a lot of—I'm trying to think of a good word—superstition, I guess, among pediatric urologists that there are more torsions when the weather changes," North said. "So when you get your first very cold or very hot days, there's a mythology that we see a lot more torsions in those days. It's actually not been proven scientifically that it's true. Anecdotally, it certainly feels like it makes sense."

Prevention of testicular torsion

We have a dire condition that can result in the loss of a testicle in as little as six hours and has no clear cause: How on Earth can you prevent it?

The bad news is you really can't.

As they say, though, knowing is half the battle. Perhaps when it comes to the prevention of something that's still relatively mysterious and doesn't have a clear pattern of cause and effect, the best anyone can hope for is to educate themselves to recognize the following signs:

• Sudden onset of continual, severe pain in the testicle lasting more than 30 minutes
• Nausea
• Vomiting
• Swelling
• Tenderness to the touch
• One testicle positioned higher than usual or at a strange angle
• Changes in scrotum color, particularly redness or darkening
• A visible lump in the testicle
• Fever

"First of all, I think educating—especially teenage boys—is super-important, especially those 15-, 16-year-old boys who are really at the highest risk," North said. "It can be at any age, but the peak is in adolescence, so really educating teenage boys on the importance of telling an adult if you have testicular pain is really important."

Complications of testicular torsion

Surgery is required to correct testicular torsion. As any surgery can, making an incision in the scrotum to access the testicle can potentially create complications, such as an infection or the stitches opening up. By and large, however, the procedure to repair testicular torsion runs a minimal risk.

One thing to be aware of, though, is when the surgeon treats torsion and leaves a borderline testicle in the scrotum. A urologist may err on the side of optimism and leave a testicle intact if it might have a chance to survive. The worst-case scenario is that the questionable testicle atrophies and shrinks significantly within about six months. The best case is the blood flow is restored and the patient gets to keep both testicles.

However, with an injury or infection to a testicle (or the prostate gland), there's a small chance the body may produce what are called antisperm antibodies, an immune response that treats sperm cells as though they are invaders.

"There's a hypothetical risk of antisperm antibodies when you leave a dead testicle in. That's why [with] the really dead ones, we don't," North said. "But I always feel like the kid—or the man, if it's an adult—would rather have two testicles than one. To me, that theoretical risk doesn't outweigh the benefits of trying to keep the testicle."

Maybe try to keep both of them?

The best anyone can really do to prevent testicular torsion is to make sure they know the signs. Anyone in the most at-risk groups—teenage boys being at the top of that list—needs to know that if you have severe, sustained testicular pain, you need to tell someone right away. Don't let the potential awkwardness of the conversation lead to permanent damage.

The risk of losing a testicle is not worth avoiding the perceived embarrassment of talking about your balls.