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You might have bell's clapper syndrome which is simply that your testicle does not have the usual gubernaculum scrotal ligament holding it in place at the very bottom of the scrotum and/or lack the usual attachment between the spermatic cord and the testicle where the cords attach to the top of each testicle. This allows your testicle to hang more flat and less vertical than normal. It is not harmful or dangerous. 1 in every 8 men have a detached or missing gubernaculum ligament and have no problems at all. They function perfectly normal except that their testicles can move around, twist, and retract far up inside their body and leave the scrotum during cold, sexual excitement, orgasm, ejaculation, and other causes. They will normally drop back down into the scrotum by themselves after a very short time (less than one hour). But 1 in males, normally pre-teens, teens, and twenties aged younger males (but any age males into very old age can get trosion) , get testicular torsion. Men with Bell's clapper can have testicular torsion as they lack the usual attachments that keep testis from rotating and twisting up on their spermatic cords, which is a medical emergency needing a Dr.s' care within less than 2 to 6 hours to best save a testicle from dying from a lack of blood flow. Testicular torison is usually very painful, sudden, or numbs the testicle. But highly moveable or retractable testicles are not rare or any problem for most men and boys. Most males with one testicle lacking gubernaculum fixation are very likely to lack fixation on both testicles with no problem or harm involved.
What is testicular torsion?
The spermatic cord provides blood flow to the testicle. When a testicle rotates on this cord, it is referred to as testicular torsion; it causes the flow of blood to stop, causing sudden, often severe pain, and swelling.
Prolonged testicular torsion and loss of blood flow can lead to the death of the testicle and surrounding tissues. Testicular torsion is serious but treatable.
Causes of testicular torsion
Each testicle is attached to the spermatic cord and the scrotum. Testicular torsion happens if the testicle rotates on the cord that runs upward from the testicle into the abdomen.
The rotation twists the spermatic cord and reduces blood flow. If the testicle rotates several times, blood flow can be entirely blocked, causing damage more quickly.
Males who experience testicular torsion may have an inherited trait that allows one or both testicles to rotate freely inside the scrotum. The testicle is only attached to the spermatic cord, and not to the scrotum. This is called a “bell clapper scrotum,” because the testicle “swings” like a bell clapper.
Testicular torsion can happen at any time, while standing, sleeping, exercising, or sitting, and with no apparent trigger in those who are susceptible. Sometimes it is prompted by an injury or because of rapid growth during puberty.
Factors that increase the chance of testicular torsion are:
Age: Testicular torsion is most common in males aged years. It can occur at any age, but it is rare over the age of 30 years. About 65 percent of cases occur in adolescents aged ; it affects around 1 in 4, males before the age of
Previous testicular torsion: If the torsion occurs once and resolves without treatment, it is likely to happen again in either testicle, unless surgery is performed to correct the underlying problem.
Climate: Torsions are sometimes called “winter syndrome,” because they often happen when the weather is cold. The scrotum of a man who has been lying in a warm bed is relaxed. When he leaves the bed, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.
Testicular torsion in newborns and infants
Sometimes, testicular torsion happens before birth. In this case, the testicle cannot normally be saved, but correctional surgery is recommended after birth to diagnose and correct testicular torsion in the other testicle and to prevent future reproductive problems.
Symptoms of testicular torsion
An individual who experiences testicular torsion may have:
- Sudden or severe pain in one testicle
- Swelling of the scrotum, the loose bag of skin under the penis that contains the testicles
- Lumps in the scrotum
- Blood in the semen
- Abdominal pain
The man may also notice that one testicle is positioned higher than normal or at an odd angle. The affected testicle may become larger, and it may become red or dark in color.
Symptoms usually appear suddenly, although in some cases, the torsion can develop over a few days.
It is important to seek emergency care for sudden or severe testicle pain. The signs and symptoms may be caused by another condition, but prompt treatment can prevent severe damage or loss of the testicle if it is testicular torsion.
If there is sudden testicle pain that goes away without treatment, it may be that a testicle has twisted and then untwisted without intervention. This is known as intermittent torsion and detorsion.
Even if the testicle untwists on its own, it is important to seek prompt medical help, because surgery may be needed to prevent the problem from happening again.
Diagnosing testicular torsion
Testicular torsion is normally an emergency. Diagnosis and treatment must be rapid.
The doctor will examine the scrotum, testicles, abdomen, and groin and will ask questions about symptoms to find out whether the problem is testicular torsion or another condition.
The doctor may also test the patient’s reflexes by lightly rubbing or pinching the inside of the thigh on the affected side. This normally causes the testicle to contract. This reflex probably will not occur if there is testicular torsion.
If the diagnosis is uncertain, a urologist will be consulted immediately, to avoid compromising the health of the testicle.
Medical tests that can confirm a diagnosis or to help identify another problem include:
- Urine or blood tests to check for infection
- Scrotal ultrasound to assess blood flow – decreased blood flow can be a sign of testicular torsion
- Nuclear scan of the testicles – this involves injecting tiny amounts of radioactive material into the bloodstream to detect areas of reduced blood flow
Exploratory surgery may be necessary to identify whether symptoms are caused by testicular torsion or another condition. It surgery does not reveal torsion, the surgeon may still attach the testicle to the scrotum wall, to prevent future problems.
If pain has lasted for several hours and the physical exam suggests testicular torsion, surgery may be performed without additional testing, to prevent the loss of the testicle.
Treating testicular torsion
Testicular torsion normally requires emergency surgery. If treated within hours, the testicle can usually be saved, but waiting longer can cause permanent damage and may affect the ability to father children.
The surgeon will untwist the spermatic cord to restore blood supply.
Manual detorsion is sometimes possible, but carrying out surgery can prevent a recurrence.
The operation is simple and minimally invasive. It is normally conducted under general anesthesia, and it does not usually require a stay in the hospital.
During surgery, the doctor will:
- Make a cut in the scrotum
- Untwist the spermatic cord, if necessary
- Stitch one or both testicles to the inside of the scrotum, to prevent rotation
Suturing both testicles will prevent torsion from occurring on the other side.
The sooner the testicle is untwisted, the greater the chance of successful treatment. After 6 hours, lasting damage may occur, and after 12 hours, there is a 75 percent chance of losing the testicle.
Once the testicle is dead, it must be removed to prevent gangrenous infection.
After surgery, the patient will need to avoid strenuous activity and sexual activity for several weeks.
Prevention and prognosis
Having testicles that can rotate or move back and forth freely in the scrotum is an inherited trait. Some males have this attribute and others do not.
The only way to prevent testicular torsion for a man with this trait is through surgery to attach both testicles to the inside of the scrotum so that they cannot rotate freely.
The majority of cases, if treated within 6 hours, do not require the removal of the testicle (orchiectomy). However, if treatment is delayed for 48 hours, the majority of patients do need to have the affected testicle removed.
Rarely, torsion happens on both sides, but only in around 2 out of every If a testicle is removed, it does not mean that a man cannot have children. The remaining testicle will still produce sufficient sperm to conceive. However, low sperm count has been observed in men who have undergone a torsion.
Additionally, an orchiectomy can alter hormone production in infants.
Sometimes, the remaining testicle will grow larger to compensate. The man should consider wearing protective clothing when doing sports and other activities, to preserve the second testicle.
Written by Christian Nordqvist
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Testicular torsion occurs when the spermatic cord and its contents twistswithin the tunica vaginalis, compromising the blood supply to the testicle.
Testicular torsion is a surgical emergency, as without treatment the affected testicle will infarct within hours. Whilst theoretically it can occur at any age, peak incidence is in neonates and adolescents between the ages of yrs.
Torsion occurs when a mobile testis rotates on the spermatic cord. This leads to reduced arterial blood flow, impaired venous return, venous congestion, resultant oedema and infarction to the testis if not corrected.
Males with a horizontal lie to their testes, often termed a ‘bell-clapper deformity’, are more prone to developing testicular torsion. In this anatomical variant, the testis lacks a normal attachment to the tunica vaginalis and is therefore more mobile, increasing the likelihood of it twisting on the cord structures.
Neonatal Testicular Torsion
In neonates the attachment between the scrotum and tunica vaginalis is not fully formed and the entire testis and tunica vaginalis can tort; this is known as ‘extra-vaginal torsion’.
It is important to note that this can occur in-utero and new-borns must be thoroughly examined at their first check. Almost all other torsions will be ‘intra-vaginal’, with the freely moving cord and testis torting within the tunica vaginalis.
The main risk factors for developing a torsion are:
- Age (most common yrs)
- Previous testicular torsion*
- Family history of testicular torsion
- Undescended testes
*Previous non-specific episodes of testicular pain that have previously self-resolved could be a sign of previous torsion with self-detorsion
Patients will generally present with sudden onset severe unilateral testicular pain. This is often associated with nausea and vomiting, secondary to the pain. Referred abdominal pain can also occur.
On examination, the testis will have a high position* (compared the contralateral side) with a horizontal lie. It can also appear swollen and will be extremely tender.
Classically, the cremasteric reflex is absent and pain continues despite elevation of the testicle, termed a negative Prehn’s sign (whilst in epididymo-orchitis, Prehn’s test is often positive).
*It is often worth clarifying with the patient the normal position of their testes in their scrotum (i.e. which testis normally sits higher)
The most common differential to exclude is epididymo-orchitis; this is normally associated with a more gradual onset of pain and can be associated with LUTS and / or pyrexia.
Other differentials to consider include trauma, incarcerated inguinal hernia, testicular cancer, renal colic, hydrocele, idiopathic scrotal oedema, and torsion of the hydatid of Morgagni.
Torsion of the Hydatid of Morgagni
The hydatid of Morgagni is a remnant of the Mullerian duct and is a common testicular appendage. This structure can also become torted, presenting with similar sudden onset pain.
Torsion of these structures is more common in a younger age group than testicular torsion, and the scrotum is usually less erythematous with a normal lie of the testis.
The ‘blue dot’ sign may be present in the upper half of the hemiscrotum, which is the visible infarcted hydatid.
The diagnosis of testicular torsion is a clinical one, therefore any suspected cases should be taken straight to theatre for scrotal exploration.
However, in cases with sufficient equipoise, Doppler ultrasound (Fig. 4) can be used to investigate potential compromised blood flow to the testis (if available, this test has a high sensitivity (89%) and specificity (99%)).
A urine dipstick can also be performed to assess for any potential infective component, as part of potential differentials.
Testicular torsion is a surgical emergency with a hrs window from the onset of symptoms to salvage the testis before significant ischaemic damage occurs.
Any suspected case warrants urgent surgical exploration of the testis to assess the testes and the spermatic cord for evidence of torsion.
Patients should be provided with suitable strong analgesia and anti-emetics pre-operatively, and made nil by mouth with maintenance fluids prescribed.
If torsion is confirmed intra-operatively, the cord and testis will be untwisted and both testicles fixed to the scrotum, termed bilateral orchidopexy (prevent further any further torsion episodes).
In cases where the testis is non-viable, an orchidectomymay be warranted; prosthesis can be inserted at time of surgery or at a later date, at the patient request.
Delay in surgical exploration leading to prolonged ischaemia can result in testicular infarction; the chance of this happening increases exponentially with time since onset of pain*.
Despite expedient scrotal exploration, de-torsion, and orchidopexy, the affected testis may later undergo atrophy. Patients undergoing scrotal exploration should be consented for chronic pain, palpable suture, risk to future fertility, and a theoretical risk of future torsion despite fixation.
*Testicular salvage rates are % if surgery performed within 6hrs of onset of pain, and this decreases to 50% if symptoms are present for more than 12 hours
- Testicular torsion is a surgical emergency
- It presents with sudden onset severe unilateral testicular pain
- Suspected cases warrant urgent surgical exploration
- Confirmed cases intra-operatively will require bilateral orchidopexy
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