Testicular torsion in Sub-Saharan Africa: a scoping review
African Journal of Urology volume 29, Article number: 50 (2023)
Testicular torsion is a surgical emergency caused by rotation of the vascular pedicle of the testicle around its axis. If left untreated, testicular necrosis can set in, necessitating orchiectomy and loss of the testicle. The authors of this article reviewed articles on testicular torsion published in sub-Saharan Africa. The aim of this work is to establish the patient profile, consultation delay and orchiectomy rate in the sub-Saharan context. Data from the review will be compared with large non-sub-Saharan series and journals. Twenty-three articles were selected for review. All these articles were published between 1985 and 2022. A total of 1410 patients were included in the review. The average age was 19.7 years. The majority of patients were from urban areas. Risk factors for torsion were identified in 9 publications. The mode of hospital admission varied. Acute scrotal pain was the main symptomatology reported. The mean time in hours between onset of symptoms and consultation was 52.5 h. The left side was affected in 46.04% and the right in 49.81%. Four authors reported referral to a health center, and 8 authors reported scrotal ultrasonography. The rate of orchiectomy performed was found in 21 publications, the mean for the review as a whole was 46.4% with extremes of 13.2 and 72%. The orchiectomy rate was 52.4% in studies that reported an initial referral to a health center (patient transfer), versus 36.9% in studies that did not. In studies reporting ultrasound, the orchiectomy rate was 52.5%, compared with 36.9% in those not reporting ultrasound. On the basis of these results, we can formulate the following recommendations and actions: (i) further study of this pathology in sub-Saharan countries; (ii) raise public awareness of this pathology; (iii) train and retrain community workers and health center managers; and (iv) train general practitioners and surgeons in emergency scrototomy, orchidopexy and orchidectomy.
Testicular torsion is a surgical emergency due to rotation of the vascular pedicle of the testis around its axis, preventing blood flow to the testis and scrotal contents . Typically, it presents spontaneously as a large, painful, acute bursa in an adolescent or young adult . The main differential diagnoses are: orchiepididymitis, scrotal trauma, subacute testicular cancer, etc. . Rotation and constriction lead to acute ischemia and then testicular necrosis if not managed rapidly . It should always be considered as an absolute surgical emergency and a race against time [3, 5]. Mellick et al. , in a review reported a testicular salvage rate of 97.2% when the patient presented within the first 6 h of the onset of symptomatology and 7.4% after 48 h. In case of viability, the testicle is untwisted followed by orchidopexy. In case of necrosis, orchiectomy is required . Because of the functional and medico-legal stakes, testicular torsion is a well-known surgical emergency in developed countries . In Africa, there are few data on testicular torsion , and its incidence is slightly lower than in Western countries . The primary objective of this review is to establish an epidemiological status defining the patient profile, consultation time and orchiectomy rate in the sub-Saharan context. Secondly, it will compare its data to large non-sub-Saharan series and reviews. Finally, at the end of the analysis, the authors will propose recommendations if needed and actions to be taken.
2.1 Search strategy and eligibility criteria
The review was performed without time restriction. The academic databases searched included PubMed, Google Scholar, and African Journals Online. A total of 23 articles that met our inclusion criteria were used for this review. From these 23 articles, data extraction was performed. Literature search was performed in September 2022. The PICO definition used was as follows: P: Patients (patient managed for testicular torsion), I: Interventions (scrototomy, orchidopexy, orchidectomy), C: Comparison (epidemiology, presentation, and operative outcome compared to literature outside of sub-Saharan Africa), and O: Outcomes (time to presentation and final outcome of scrototomy). The following keywords were used: “torsion,” “testis,” “acute testicular pain”, “testicular torsion,” “acute scrotum,” “TWIST,” “orchidectomy”, “suspected torsion,” “Africa'' and “sub-Saharan African countries.” The search was limited to human studies in Sub-Saharan Africa with limitations on publication in English or French Languages. Conference abstracts were included.
Three reviewers to allow for an independent triple-check of articles and data. Comparative studies, prospective and retrospective cohort and cross-sectional studies were included. Review articles and conference abstracts, Incomplete or impossible to extract data, articles dealing with perinatal or purely pediatric torsion and case reports were excluded. References within and citations of all included articles were screened for completeness. Full texts were evaluated against predetermined criteria: (1) original research of (2) adult and pediatric males presenting with acute scrotum who were (3) evaluated using TWIST and (4) received a diagnosis of positive or negative TT. Disagreements over study eligibility were resolved by discussion between the reviewers.
2.2 Data extraction
Data from the articles were entered into a google form and extracted. Data including study location: country, town, center name and geographic area, article citation details, study design, study duration, population demographics, population history and physical evaluation, TT risk factors, patients paraclinical investigation, surgery details were extracted. The result was then tabulated for each article. Corresponding authors were contacted to retrieve elements missing from their manuscripts.
2.3 Outcome measures
The primary outcomes of interest were (1) epidemiologic characteristics of TT in sub-Saharan Africa, (2) Compare our findings with non-sub-Saharan own. The most represented age group and the average time between the onset of the symptomatology and the consultation were not uniformly reported. The most represented age group could not be analyzed in a grouped fashion. For the mean time to consultation, the analysis included studies that reported the mean time in hours.
2.4 Statistical analysis
Data from the articles were entered into a google form and extracted for analysis using Microsoft Office Excel Software 2021 for quantitative and qualitative. The analysis was univariate and bivariate. Results are expressed as mean and percentage. The mapping was generated by Bing Excel image.
After an initial search and selection, 23 articles [2, 9, 11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31] were selected. All articles were published between 1985 and 2022. They covered epidemiology, clinical aspects, intraoperative findings and procedures performed. Publications came from: 1 from South Africa, 1 from Benin, 3 from Burkina Faso, 1 from Congo, 1 from Gabon, 1 from Guinea Conakry, 1 from Kenya, 10 from Nigeria, 3 from Senegal and 1 from Uganda (Fig. 1).
All studies were retrospective and monocentric in 95.6% of cases. All centers were located in urban areas. A total of 1,410 patients were included in the review, with extremes of 22 and 308 patients. The mean age of the review was 19.7 years, with extremes of 17.2 and 27 years. Seven authors reported that the majority of their patients were from urban areas. In 14 publications, the patients' area of origin was not reported (Table 1).
Ten authors reported a history of spontaneously resolving scrotal pain, and a further 6 authors reported a history of scrotal surgery for testicular torsion. Risk factors for torsion were identified in 9 publications: cold, trauma and congenital anomalies. The mode of hospital admission varied: consultation, emergency and transfer. In 4 publications, the mode of admission was not reported. Acute scrotal pain was the main symptomatology reported in 22 publications. Twelve authors reported the average time (in hours) between onset of symptoms and consultation. The mean was 52.5 h, with extremes of 5 and 108 h. The side affected was reported by 20 authors: left in 46.04% and right in 49.81%. Bilateral involvement was reported in 4 publications. In 4 articles, patients were referred to a health center.
Of the articles studied, 8 reported scrotal ultrasound. The rate varied from 4.1 to 71%, with an average of 30.9% for the 8 authors.
The rate of orchiectomy performed was found in 21 publications; the average for the review as a whole was 46.4%, with extremes of 13.2% and 72%. For orchidopexy, the review average was 60.6%, with extremes of 28 and 93.7%. Sixteen authors reported contralateral orchidopexy in addition to the initial procedure. In 10 publications, early complications were reported (hematoma, orchitis, parietal suppuration/abscess, delayed healing). For late complications, only testicular atrophy was reported by 3 authors.
Table 2 shows data on duration, ultrasound and percentage of orchiectomy.
In publications reporting the notion of spontaneously resolving scrotal pain, the orchiectomy rate was 36.8%, compared with 43% in publications that did not. The orchiectomy rate was 52.4% in studies that reported an initial referral to a health center (patient transfer), versus 36.9% in studies that did not. When analyzing mode of admission and outcome of exploration, the orchiectomy rate was 29.2% in studies where the majority of patients were recruited via the emergency department, 56.8% by transfer, 48.9% via consultation. In studies where ultrasound was reported, the orchiectomy rate was 52.5%, compared with 36.9% in those where it was not. The mean orchiectomy rate was 19%, 48.4% and 44.1%, respectively, for studies reporting a mean time from symptom onset to consultation of less than 6 h, between 6 and 24 h and greater than 24 h.
Acute scrotum is a common emergency presentation to surgical and emergency units. Diagnosis of TT is challenging and time critical.
In Indonesia, 80.2% of patients consulted after 6 h . In Brazil, the overall mean delay in a study that included 21289 patients was 6 h. This mean delay varied according to the level of the center (5.2 h for primary facilities, 8.4 h for secondary facilities, and 10.1 h for tertiary centers) . In France, the average presentation time reported in a multicenter study was 5 h . In Morocco, in a study of neglected testicular torsions, the mean time to presentation was reported to be 86 h . In a systematic review including 2116 patients, testicular recovery within the first 12 h was 90.4%, survival from 13 to 24 h was 54.0% and survival beyond 24 h was 18.1%. The authors of this review concluded that aggressive management of patients with symptomatology lasting for many hours should be encouraged . All his previous studies cited reported an average delay in presentation. This shows the importance of this parameter in the management of testicular torsion. In our review, the delay was well over 24 h, but this should not delay investigation in the face of a typical history and presentation.
Torsion is a time-dependent event, and factors (distance from hospital and delay associated with transfer to hospital) that delay time to treatment result in a high rate of testicular loss . El Mehdi et al.  reported that 15% of their patients with testicular loss were from rural areas. We found an association between the mode of admission and the probability of testicular salvage. The sooner the patient presents to a center with surgical expertise, the higher the rescue rate. In addition to the mode of admission, the area from which patients come and the location of the centers can impact the outcome of surgical exploration.
In our review, the orchiectomy rate was high in publications where the authors reported the performance of scrotal Doppler ultrasound. For medico-legal reasons, Pepe et al.  performed a Doppler ultrasound in any patient with an "acute scrotum". But a normal result does not contraindicate surgical exploration in case of suspected testicular torsion. Pinar et al.  reported that scrotal Doppler ultrasound before surgery was safe, feasible and useful in selected cases with suspected testicular torsion, but it should not delay surgery in cases of strong suspicion. In our context, it would be preferable to systematically explore urgently any scrotal pain suggestive of testicular torsion.
The rate of orchiectomy is highly variable in the literature: 7.6% in France , 23% in Australia  and 24.3% in Korea  and 100%  in Morocco. Testicular salvage depends on presentation, diagnosis and timely surgical intervention . Lee et al.  in comparing their orchiectomy rate with other data in the literature pointed out the geographical size of the territory, the dense distribution of hospitals and health insurance allowing easy access to care centers. In this review, the average orchiectomy rate is 46.4% with extremes of 13.2% and 72%. Several factors may explain these figures in sub-Saharan Africa: delay in consultation, distance of referral centers from primary care centers, diagnostic erraticism, and access to care centers that require payment. In general, this rate may be related to the level of socio-economic development of the country.
Our review reports the performance of contralateral orchidopexy in 10 publications. A study that included 2912 patients evaluated the complications secondary to the performance of a systematic immediate contralateral orchidopexy. It was found that the group of patients in whom an immediate contralateral orchidopexy was performed had more early postoperative complications (scrotal hematoma and delayed healing) than patients who did not have an immediate contralateral orchidopexy. The authors of this publication concluded that the performance of immediate contralateral orchidopexy should be limited and should be performed after informing the patient of its risks and possible benefits . In sub-Saharan Africa, to avoid the risk of testicular loss related to several factors, we believe that it would be preferable to perform contralateral orchidopexy if the conditions allow (absence of significant edema, absence of infectious complications). The patient's consent must be systematically obtained before this procedure and he must be informed about the possibility of immediate contralateral orchidopexy and its postoperative complications. A close and strict follow-up must be defined, in order to detect and manage any complication in time.
In the African environment, surgical emergencies are characterized by the inadequacy between the needs of the patients and the means of diagnosis and treatment . In addition, there are problems of triage, diagnosis and decision making. The rapidity of adequate treatment, the execution of precise and rapid gestures with the minimum of therapeutic materials  are indispensable . For this reason, it is important to train the first level staff on this urgent pathology. The learning, use and dissemination of predictive tools such as the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can contribute to increase  the suspicion of this pathology in front of any acute testicular pain . Furthermore, this score has high positive and negative predictive values even when used by non-physicians . This emergency scrotal surgery, which does not require too much technical skill, should also be taught to general practitioners practicing in remote areas and to general surgeons in secondary centers.
Several studies have shown that most parents and boys are unaware of the urgency of early assessment of acute scrotal pain, which in turn can lead to testicular loss due to delayed treatment . The high rate of orchiectomy in our review calls for urgent community education in Africa. It is our responsibility as urologists and pediatric surgeons to devise effective strategies to educate our communities to reduce the risk of testicular loss and prevent the sequelae of delayed treatment of torsion.
Sub-Saharan Africa is a large geographic area with a predominantly young population. In this area, lack of accessible surgical care at the district level due to several factors has been identified as an underlying cause of delayed care . Testicular torsion, one of the major urological emergencies that occur in adolescents, is rarely reported. This is reflected in the number of publications available. This review of 1410 patients from sub-Saharan Africa found that the delay between onset of pain and consultation is late and the rate of orchiectomy is high in some countries, up to 72%. Any acute scrotal pain must be considered as a torsion of the testicular cord until proven otherwise, because the vital prognosis of the testicle and fertility depends on the rapidity of the management. Its management should be one of the indicators of access to timely essential surgery, which are the goals of global surgery . In sub-Saharan Africa, to improve the management of testicular torsion, we make the following recommendations: raise public awareness of testicular torsion, retrain health center managers on this emergency, and train general practitioners and surgeons to perform exploratory scrototomies.
Availability of data and materials
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
Pentyala S, Lee J, Yalamanchili P, Vitkun S, Khan SA (2001) Testicular torsion: a review. J Low Genit Tract Dis 5(1):38–47. https://doi.org/10.1046/j.1526-0976.2001.51008.x
Bah OR, Rouprêt M, Guirassy S, Diallo AB, Diallo MB, Richard F (2010) Aspects cliniques et thérapeutiques de la torsion du cordon sperma- tique: étude de 27 cas. Prog Urol 20:527–531
Audenet F (2012) Torsion du cordon spermatique et des annexes testiculaires: physiopathologie, diagnostic et principes du traitement. EMC Urologie 5(2):1–7
Visser AJ, Heyns CF (2003) Testicular function after torsion of the spermatic cord. BJU Int 92:200–203
Kapoor S (2008) Testicular torsion: a race against time. Int J Clin Pract 62(5):821–827
Mellick LB, Sinex JE, Gibson RW, Mears K (2019) A systematic review of testicle survival time after a torsion event. Pediatr Emerg Care 35(12):821–825. https://doi.org/10.1097/PEC.0000000000001287
Jacobsen FM, Rudlang TM, Fode M, Østergren PB, Sønksen J, Ohl DA, Jensen CFS (2020) CopMich collaborative. The impact of testicular torsion on testicular function. World J Mens Health. 38(3):298–307. https://doi.org/10.5534/wjmh.190037
Colaco M, Heavner M, Sunaryo P, Terlecki R (2015) Malpractice litigation and testicular torsion: a legal database review. J Emerg Med 49(6):849–854. https://doi.org/10.1016/j.jemermed.2015.06.052. (Epub 2015 Sep 26 PMID: 26409673)
Sarr A, Fall B, Mouss B, Sow Y, Thiam A, Diao B, Diagne BA (2010) Aspects diagnostiques et thérapeutiques de la torsion du cordon spermatique au CHU Aristide-Le-Dantec de Dakar. Basic Clin Androl 20(3):203–208
Thibaut LD, Chiron P, Bourgouin S, Hardy J, Deledalle FX, Laroche J, Savoie PH (2022) Prise en charge de la torsion du testicule par un chirurgien généraliste isolé en Afrique. Méd Trop Santé Int. https://doi.org/10.48327/mtsi.v2i2.2022.230
Udeh FN (1985) Testicular torsion: Nigerian experience. J Urol 134(3):482–484
Obi AO, Okeke CJ, Ugwuidu EI (2020) Acute testicular torsion: a critical analysis of presentation, management and outcome in southeast Nigeria. Niger J Clin Pract 23(11):1536
Ibrahim AG, Aliyu S, Mohammed BS, Ibrahim H (2012) Testicular torsion as seen in University of Maiduguri teaching hospital, North East Nigeria. Borno Med J 9(2):31–33
Kuranga SA, Rahman GA (2002) Testicular torsion: experience in the Middle Belt of Nigeria. Afr J Urol 8(2):78–82
Ogbetere FE (2021) Traumatic testicular torsion: a call to look beyond the obvious. Urol Ann 13(4):431
Abu S, Atim T, Obiategwu KO, Okpako IO, Magnus FE (2020) Does the source of referral affect the outcomes of testicular torsion? Niger J Med 29(4):607
Kabore FA, Kabore KK, Kabore M, Kirakoya B, Yameogo C, Ky BD, Zango B (2021) Predictive factors for orchiectomy in adult’s spermatic cord torsion: a case-control study. Basic Clin Androl 31(1):1–5
Odzebe AWS (2018) Torsion du cordon spermatique et des annexes testiculaires chez le sujet adulte au CHU de Brazzaville. Revue Africaine d'Urologie et d'Andrologie 1(9)
Ndang S, Mougougou A, Massande J, Nguema B (2018) Délai de prise en charge de la torsion du cordon spermatique au CHU de Libreville. Bull Med Owendo. 16(45):26–31
Njeze GE (2012) Testicular torsion: needless testicular loss can be prevented. Niger J Clin Pract 15(2):182–184
Murithi J, Mwachi A, Abdalla R, Chavda S (2017) Management and outcome of testicular torsion. Ann Afr Surg 14(2)
Ouattara A, Pare AK, Kabore FA, Yameogo CAM, Rouamba M, Ye D, Bako A, Kambou T (2020) Burkina Faso. Aspects cliniques et thérapeutiques des torsions du cordon spermatique au Centre Hospitalier Universitaire Souro Sanou de Bobo-Dioulasso (Burkina Faso). Médecine d'Afrique Noire 6704 – Avril, 214–220
Kaboré FA, Zango B, Yaméogo C, Sanou A, Kirakoya B, Traoré SS (2011) Les torsions du cordon spermatique chez l’adulte au CHU Yalgado Ouédraogo de Ouagadougou. Basic Clin Androl 21(4):254–259
Diaw EM, Ndiath A, Sine B, Sow O, Ndiaye M, Sarr A et al (2020) Torsion du cordon spermatique: aspects épidémiologiques, cliniques et thérapeutiques au Centre hospitalier universitaire Aristide Le Dantec. Jaccr Africa 4(4):56–60
Mukendi AM, Kruger D, Haffejee M (2020) Characteristics and management of testicular torsion in patients admitted to the Urology Department at Chris Hani Baragwanath Academic Hospital. Afr J Urol 26(1):1–8
Ugwu BT, Dakum NK, Yiltok SJ, Mbah N, Legbo JN, Uba AF, Ramyil VM (2003) Testicular torsion on the Jos Plateau. West Afr J Med 22(2):120–123
Ugwumba FO, Okoh AD, Echetabu KN (2016) Acute and intermittent testicular torsion: analysis of presentation, management, and outcome in South East, Nigeria. Niger J Clin Pract 19(3):407–410
Bello JO (2018) Burden and seasonality of testicular torsion in tropical Africa: analysis of incident cases in a Nigerian community. Afr J Urol 24(1):79–82
Diallo Y (2019) All torsion of the spermatic cord: clinical and therapeutic aspects in the Region of Thies (Senegal). Adv Reprod Sci 7:60–70
Hodonou R, Soumanou-Kaffor R, Akpo C (1999) La torsion du cordon spermatique: facteurs etiopathologiqur, diagnostiques et thérapeutique: a propos de 33 cas au CNHU Cotonou. Med d'Afr Noir 46(2)
Ibingira, C. B. R. (2001). Management of testicular torsion in Mulago Hospital over a 5-year period. East Central Afr J Surg 6(2)
Rulianov R, Adi K, Safriadi F (2022) A ten-year study on risk factors of orchiectomy in testicular torsion. Maj Kedokt Bdg 54(2):125–130
Korkes F, Cabral PRDA, Alves CDM, Savioli ML, Pompeo ACL (2012) Testicular torsion and weather conditions: analysis of 21,289 cases in Brazil. Int Braz J Urol 38:222–229
Pradere B, de Varennes AM, Benali NA, Vallée M, Berchiche W, Gondran-Tellier B, Khene ZE (2022) Torsion of the spermatic cord in adults: a multicenter experience in adults with surgical exploration for acute scrotal pain with suspected testicular torsion. Asian J Androl 24(6):575–578
El Mehdi W, Youssef B, Adnane E, Dakir M, Adil D, Rachid A (2021) Neglected spermatic cord twisting: experience of the University Hospital Center of Casablanca. Eur J Med Health Sci 3(1):181–185
Bayne AP, Madden-Fuentes RJ, Jones EA, Cisek LJ, Gonzales ET, Reavis KM, Hsieh MH (2010) Factors associated with delayed treatment of acute testicular torsion—do demographics or interhospital transfer matter? J Urol 184(4S):1743–1747
Pepe P, Panella P, Pennisi M, Aragona F (2006) Does color Doppler sonography improve the clinical assessment of patients with acute scrotum? Eur J Radiol 60:120–124
Pinar U, Duquesne I, Lannes F, Bardet F, Kaulanjan K, Michiels C, Pradere B (2021) The use of doppler ultrasound for suspected testicular torsion: lessons learned from a 15-year multicentre retrospective study of 2922 patients. Eur Urol Focus. https://doi.org/10.1016/j.euf.2021.02.01110.1016/j.euf.2021.02.011
Dunne PJ, O’Loughlin BS (2000) Testicular torsion: time is the enemy. Aust N Z J Surg 70(6):441–442
Lee SM, Huh JS, Baek M, Yoo KH, Min GE, Lee HL, Lee DG (2014) A nationwide epidemiological study of testicular torsion in Korea. J Korean Med Sci 29(12):1684–1687
Duquesne I, Pinar U, Bardet F, Dominique I, Kaulanjan K, Matillon X, Pradère B (2020) Orchidopexie controlatérale dans le temps de l’exploration scrotale pour suspicion de torsion: est-ce vraiment sans risque? Prog Urol 30(13):727
Andreu JM (2002) Urgences chirurgicales en milieu africain (l’urgence tropicale existe-t-elle ?). Med Trop 62:242–243
Mignonsin D. Pratique des urgences en Afrique. Revue Africaine d’anesthésiologie et de médecine d’urgence Janvier 2014.
Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC et al (2013) Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol 189:1859–1864 (Erratum in: J Urol. 2014;192:619)
Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG et al (2016) Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score. J Urol 195:1870–1876
Yap LC, Keenan R, Khan J et al (2018) Parental awareness of testicular torsion amongst Irish parents. World J Urol 36(9):1485–1488
Mukhopadhyay S, Lin Y, Mwaba P, Kachimba J, Makasa E, Lishimpi K et al (2017) Implementing World Health Assembly Resolution 68.15: national surgical, obstetric, and anesthesia strategic plan development—the Zambian experience. Bull Am Coll Surg 102:28–35
Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA et al (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569–624
Ethics approval and consent to participate
Consent for publication
No competing interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Nedjim, S.A., Biyouma, M.D.C., Mahamat, M.A. et al. Testicular torsion in Sub-Saharan Africa: a scoping review. Afr J Urol 29, 50 (2023). https://doi.org/10.1186/s12301-023-00384-0