Bilateral metachronous testicular torsion presenting as alternating acute scrotal pain: a case report

¹School of Medicine, University of Health and Allied Sciences, Ho, Ghana, ²Department of Surgery, Urology Unit, University of Health and Allied Sciences, Ho, Ghana

^&Corresponding author
Frank Obeng, School of Medicine, University of Health and Allied Sciences, Ho, Ghana

Introduction    

Testicular torsion (TT) is a urological emergency caused by twisting of the spermatic cord, compromising testicular perfusion. The resulting ischemic injury is, however, potentially irreversible. It occurs predominantly during the first two decades of life, with a peak incidence in adolescence [1]. Prompt surgical intervention is required to restore perfusion and maximize the likelihood of testicular salvage [1,2]. Bilateral testicular torsion is uncommon, and bilateral metachronous testicular torsion (BM-TT), in which each testis undergoes torsion at separate times (at least 48 hours apart), is particularly rare [1-3]. The condition may occur in the presence of bilateral bell-clapper deformities, an anatomical predisposition to intravaginal torsion [3,4]. Because loss of both testes may have major endocrine and reproductive consequences, recognition of contralateral risk and appropriate fixation are important during management of unilateral torsion [2,5,6]. We report a case of a 17-year-old male with BM-TT presenting with sequential right and left scrotal pain five weeks apart, delayed presentation, bilateral bell-clapper deformities, and different degrees of testicular torsion. Emergency exploration demonstrated 450° right and 180° left torsion, with both testes remaining viable after detorsion and subsequently undergoing bilateral orchidopexy.

Patient and observation     

Patient information

Patient age/gender: a 17-year-old male, previously healthy, with no significant medical history, presented to the emergency department with severe, sudden-onset left-sided scrotal pain.

Presenting complaint: the pain had persisted for two weeks, was severe (9/10), radiated to the groin, and was associated with nausea, vomiting, fever, and malaise. He denied preceding trauma or physical exertion. Left scrotal swelling developed one week after pain onset.

Medical history: seven weeks before presentation, he had experienced a similar episode involving the right testis and sought consultation at a non-urological peripheral facility. Scrotal Doppler ultrasonography reportedly demonstrated right testicular torsion with features of ischemia, and referral to Ho Teaching Hospital (HTH) was advised. He did not attend the referral because of financial constraints and returned home after the pain subsided, believing that the condition had resolved. He reported no previous urological interventions or relevant medical conditions. His family history was unremarkable for testicular torsion or other urological disorders.

Clinical findings: at presentation, the left testis was swollen and markedly tender and could not be separately palpated within the scrotum; it was high-riding, with erythematous and edematous overlying scrotal skin. The right testis was smaller, distinctly palpable, firm, and non-tender. The cremasteric reflex was absent bilaterally. These findings, together with the acute severe unilateral scrotal pain, raised strong clinical suspicion of testicular torsion.

Timeline of current episode: the clinical course was as follows: seven weeks before presentation to the HTH emergency department, the patient developed sudden-onset right testicular pain; Doppler ultrasonography at a non-urology peripheral facility suggested right testicular torsion with ischemia, but he did not honor the referral to HTH because of financial constraints. Five weeks later (i.e., two weeks before the HTH presentation), he developed sudden severe left testicular pain rated 9/10, radiating to the groin and associated with nausea, vomiting, fever and malaise. One week before presentation, a left scrotal swelling developed. He subsequently presented to HTH, where examination and Doppler ultrasonography supported a left testicular torsion with an atrophic right testis. The complete chronology is presented in Table 1.

Diagnostic assessment: at the HTH emergency department, scrotal Doppler ultrasonography demonstrated marked abnormalities of the left testis and scrotal contents. (A) The left testis was enlarged, measuring approximately 4.2 x 2.9 x 3.7 cm (estimated volume 23.1 mL), with a heterogeneous echotexture and absence of demonstrable intratesticular vascularity on color Doppler, findings consistent with testicular torsion in the clinical context. (B) A septated anechoic fluid collection was present within the left hemiscrotum, measuring approximately 18.5 mL, consistent with a complex/septated hydrocele or reactive scrotal fluid collection. (C) The overlying scrotal skin and subcutaneous tissues were thickened, with a measured scrotal wall thickness of 4.4 mm, demonstrated on the transverse scrotal-wall image. (D) The right testis was substantially smaller, measuring approximately 3.0 x 2.8 x 2.0 cm (estimated volume 8.5 mL), with an atrophic appearance. (E) Color Doppler demonstrated only minimal residual vascularity within the right testis. Together, the sonographic findings demonstrated an enlarged, heterogeneous, and avascular left testis with associated septated scrotal fluid and scrotal wall thickening, alongside a smaller atrophic right testis with minimal vascularity (Figure 1). Before imaging, the differential diagnoses of acute scrotal pain included acute epididymo-orchitis, testicular torsion, and torsion of a testicular appendage. The delayed presentation, together with the non-availability of full details of the peripheral facility first-episode Doppler assessment, created further diagnostic and management challenges, particularly regarding the original status of the previously symptomatic right testis.

Diagnosis: the preoperative diagnosis was left testicular torsion with missed or neglected right testicular torsion. Intermittent torsion, bilateral synchronous torsion and bilateral metachronous torsion were considered as possible differential diagnoses. Emergency bilateral scrotal exploration subsequently confirmed bilateral intravaginal testicular torsion associated with bilateral bell-clapper deformities. The final diagnosis was bilateral metachronous testicular torsion, with approximately 180° torsion of the left testis and approximately 450° torsion of the right testis.

Therapeutic interventions: the patient underwent emergency bilateral scrotal exploration, detorsion, and bilateral orchidopexy (Figure 2). Intraoperatively, the left testis measured 6 x 5 x 3.5 cm, was twisted through 180°, markedly edematous and associated with a reactive hydrocele; it initially appeared dusky but became pink following detorsion, increased patient oxygenation, and application of warm saline compresses, indicating satisfactory reperfusion. The right testis measured 3 x 2 x 1.5 cm, was markedly atrophic and twisted through approximately 450°, but appeared viable after detorsion (Figure 3 and Figure 4). Both testes were completely invested within their respective tunica vaginalis and lacked posterior scrotal wall attachments, consistent with bilateral bell-clapper deformities and bilateral intravaginal torsion. Following detorsion and confirmation of viability, each testis underwent three-point permanent fixation using 3-0 polypropylene sutures. As seen in Figure 3, which is a clinical pictograph taken during surgical exploration of the testicles, the right testicle appears decreased in size (3 cm x 2 cm x 1.5 cm) and is torsed 450 degrees clockwise, as indicated by the pointing instrument. The left testis appears edematous, dusky, and grossly enlarged (6 cm x 5 cm x 3.5 cm) and is positioned in situ within its corresponding hemiscrotum in this pictograph. It was torsed 180 degrees clockwise. After warm compresses and increased oxygenation of the patient, the duskiness improved. Therefore, it was preserved, and a three-point orchidopexy was performed.

Follow-up and outcome of interventions: the postoperative recovery was uneventful, and the patient reported no further scrotal symptoms. He was discharged home with planned clinical follow-up at 2, 4 and 6 weeks and 6 months. Initial postoperative follow-up was satisfactory, with no reported recurrence of pain or other acute scrotal symptoms. However, he was subsequently lost to follow-up, and planned assessments at 9 and 12 months could not be completed. Consequently, postoperative Doppler ultrasonography, assessment of testicular volume, hormonal evaluation and semen analysis were not obtained, preventing objective assessment of longer-term anatomical and functional outcomes.

Patient perspective: the patient and his parents were counselled regarding the diagnosis, operative procedure, potential complications, testicular preservation, possible effects on future testicular function and the importance of postoperative follow-up. They expressed satisfaction with the care received and accepted the treatment provided.

Informed consent: written informed consent for publication of the case was obtained from the patient and his parents.

Discussion     

Testicular torsion is a urological emergency caused by twisting of the spermatic cord, resulting in impaired venous and arterial perfusion and potentially irreversible ischemic injury if delayed [1]. Intravaginal torsion is commonly associated with the bell-clapper deformity, in which the tunica vaginalis inadequately fixes the testis posteriorly and instead allows increased mobility of the testis, epididymis, and distal spermatic cord [1,4,6]. The deformity is reported in approximately 1% of males and is frequently bilateral, with reported bilateral involvement of approximately 66-70% [6]. Intravaginal torsion is particularly important in adolescents, who represent the peak age group for testicular torsion [2,4]. Bilateral torsion may be synchronous or metachronous; the latter occurs when torsion affects each testis at separate times, with an interval exceeding 48 hours [1,6-10]. In this case, the first episode involved the right testis and was followed five weeks later by torsion of the left testis, supporting the diagnosis of bilateral metachronous testicular torsion. Bilateral bell-clapper deformities and intravaginal torsion were confirmed at exploration (Table 2).

The principal strength of this case is the direct clinical and operative documentation of an uncommon sequence of events, including sequential contralateral symptoms, bilateral bell-clapper deformities, intravaginal torsion, and markedly different degrees of torsion between the testes. The initial Doppler assessment provided evidence of right-sided torsion before the second episode, while emergency exploration subsequently established the anatomical diagnosis. The case also illustrates an important management principle: following torsion in one testis, recognition of the contralateral bell-clapper deformity and bilateral orchidopexy are essential because the anatomical predisposition may be present on both sides [1,6-10]. In the present patient, failure to undergo definitive treatment during the first episode left the contralateral testis exposed to subsequent torsion. However, the case has limitations. Postoperative Doppler ultrasonography, serial testicular-volume assessment, hormonal evaluation, and semen analysis could not be completed because the patient was lost to follow-up; therefore, anatomical preservation cannot be equated with confirmed long-term endocrine or reproductive function. In addition, the precise duration and completeness of vascular occlusion during the two episodes cannot be established retrospectively.

Time to detorsion is an important determinant of testicular salvage, with the probability of viability generally declining substantially as ischemia is prolonged, particularly beyond approximately six hours [3,7-10]. Nevertheless, symptom duration and degree of spermatic-cord rotation should not be regarded as absolute measures of irreversible ischemic injury. In this patient, the right testis was markedly smaller and atrophic, but remained viable intraoperatively despite the preceding episode and approximately 450° torsion. The left testis, despite prolonged symptoms and approximately 180° torsion, reperfused after detorsion and conservative intraoperative measures. Differences in venous and arterial obstruction, completeness of torsion, residual perfusion, spontaneous detorsion, and intermittent torsion may contribute to variability in tissue injury [7-10]. Intermittent torsion with spontaneous detorsion may therefore have contributed to preservation in this patient, but this remains a possible mechanism rather than a demonstrated diagnosis. The disparity between the clinical history, degree of torsion, and intraoperative viability reinforces that the decision to preserve a torsed testis should incorporate direct assessment after detorsion rather than rely solely on reported symptom duration or the degree of rotation.

Doppler ultrasonography is an important diagnostic investigation in suspected testicular torsion and, in this case, demonstrated absent left-sided vascularity and markedly reduced flow in the smaller right testis. Nevertheless, imaging should complement rather than delay clinical assessment and urgent surgical exploration when torsion is strongly suspected [1-10]. The patient's first episode illustrates the consequences of delayed definitive treatment after an abnormal Doppler examination. Financial constraints prevented attendance at the referral hospital, while subsequent resolution of pain led the patient to believe that the condition had resolved. During the second episode, emergency exploration permitted preservation of both testes and bilateral orchidopexy. The case therefore illustrates the interaction between patient-level and health-system factors in emergency urological care: delayed health seeking, financial barriers, referral difficulties, and limited access to postoperative investigations can influence both immediate treatment and the ability to establish longer-term outcomes. These factors are particularly relevant in resource-constrained settings, where successful operative intervention may not be followed by adequate functional surveillance.

The case provides evidence of anatomical testicular salvage in bilateral metachronous torsion despite delayed presentation, but it cannot establish preserved endocrine or reproductive function because the planned longer-term assessments were unavailable. Its principal clinical implication is that a previous episode of testicular torsion should prompt urgent definitive management and bilateral fixation where a contralateral bell-clapper deformity is present, rather than reassurance after spontaneous resolution of pain [1,6-10]. In adolescents presenting with acute scrotal pain, testicular torsion should remain a clinical priority, and bilateral metachronous torsion should be considered when a contralateral episode has occurred previously. The case also demonstrates that preservation of a testis at surgery does not by itself establish satisfactory long-term function, emphasizing the importance of structured postoperative assessment.

Conclusion     

This case underscores the need for a high index of suspicion for testicular torsion in adolescents with acute scrotal pain, particularly within severely constrained health systems where delays can be consequential. Bilateral metachronous torsion may occur in the presence of bilateral bell-clapper deformities, yet anatomical testicular preservation may remain possible despite delayed presentation and marked torsion. Prompt evaluation, definitive treatment, and bilateral orchidopexy are therefore essential. However, anatomical preservation may not assure long-term endocrine or reproductive function, making loss to follow-up a significant limitation.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management and surgery: Frank Obeng. Surgical assistance: Samuelis Junior Agamah. Day-to-day patient care: Samuelis Junior Agamah, Frank Obeng, Kekeli Kojo Adanu and Ayamba Mahamudu Ali. Data collection and taking of clinical photographs: Selasie Owiafe, Samuelis Junior Agamah. Conceptualization and data curation: Frank Obeng, Selasie Owiafe; manuscript drafting: Selasie Owiafe, Samuelis Junior Agamah. Manuscript writing, editing, and figure finalization: Frank Obeng, Selasie Owiafe. Critical revision for important intellectual content: Frank Obeng, Kekeli Kojo Adanu and Ayamba Mahamadu Ali. All authors have read and approved the final version of the manuscript.

Acknowledgements     

We acknowledge our colleagues, health professionals in the emergency department, operating theatre and wards, and the management of the Teaching Hospital for their support in the care of the patient. We also acknowledge our house officers at that time: Christiana Oduro Batsa, Delali Nartey, Japhet Amevor, Mary Ofori-Atta, David Boateng, Benedictus Forson.

Tables and figures     

Table 1: the complete timeline of clinical events

Table 2: contrasting clinical presentations between the index case and recent publications

Figure 1: preoperative scrotal Doppler ultrasonography obtained on presentation at the Emergency Department of the Teaching Hospital: enlarged heterogeneous left testis with absent vascularity (A), septated left scrotal fluid collection (B), thickened scrotal skin and subcutaneous tissue (C), smaller atrophic right testis (D), and minimal right testicular vascularity (E)

Figure 2: surgical exploration of the testicles; the twisted/torsed right testicle is in view

Figure 3: intraoperative findings showing torsion of the right testis (A); and enlarged, dusky left testis following torsion (B)

Figure 4: after detorsion of the right testicular torsion, it looked reasonably pink for salvage; a three-point orchidopexy was thus performed on it as well

References