ORIGINAL ARTICLE
A Systematic Review of Testicle Survival Time
After a Torsion Event
Larry Bruce Mellick, MD, MS, FAAP, FACEP,*† James E. Sinex, MD, FACEP,*
Robert W. Gibson, PhD, MSOTR/L FAOTA,* and Kim Mears, MLIS, AHIP‡
Background: The time window for possible salvage and survival of a
torsed testicle is commonly thought to be 6 to 8 hours. However, survival
of torsed testicles with or without subsequent atrophy is known to occur
outside that critical time window. In this article, we performed a systematic
review of the English literature to provide a more accurate understanding of
reported time frames of testicle survival after a torsion event.
Objectives: The primary research question was to determine the relation-
ship between time to treatment and the rate of survival for testicles of male
patients presenting with testicular torsion (TT).
Methods: A systematic review of the literature was performed and struc-
tured according to PRISMA guidelines. An exhaustive library search was
performed after search strategies were developed for multiple databases
that included PubMed, Cochrane library, Ovid MEDLINE, Web of Science,
and ProQuest Theses and Dissertations. Two different searches were devel-
oped including “testicular torsion” and TTwith the search term “time” added.
Articles specifically reporting TT case series, testicle outcomes, and time to
surgical or manual treatment were selected for review. In addition to and
preceding the systematic review, an exhaustive manual search of the liter-
ature was also performed by the authors. As a result of these searches, a
total of 30 studies with data considered relevant to the research question
were included. The information extracted from the articles was tabulated
with regard to time intervals to treatment and survival outcome.
Results: The systematic review process and protocol are reported in this
article. A total of 30 studies were found that reported case series of TT patients
and their outcomes as well as time to treatment reported in useful time frames.
From these reports, a total of 2116 TT patients were culled, and their outcomes
and time to treatment are reported. Because the time to treatment was reported
variously in different case series, the 3 most common formats for reporting time
to treatment and outcome were used. When overlap between the tables existed,
the data were tallied and reported cumulatively. When reported in 6-hour
intervals (1,283 patients), survival at 0 to 6 hours was 97.2%; 7 to 12 hours,
79.3%; 13 to 18 hours, 61.3%; 19 to 24 hours, 42.5%; 25 to 48 hours,
24.4%; and greater than 48 hours, 7.4%. Moreover, we reported cumulative
survival data based on reporting for all 3 groups of patients. Testicular sal-
vage in the first 12 hours is 90.4%, from 13 to 24 hours survival is 54.0%,
and beyond 24 hours survival is 18.1%. Testicle survival after TT was sig-
nificant beyond the commonly held 6 to 8 hour time frame and even after
more than 24 hours of ischemia.
Conclusions: Survival of the testicle irrespective of subsequent atrophy,
decreased spermatogenesis or impaired endocrine function after TT can be
much longer than the 6 to 8 hours that is commonly taught. Our systematic
review of the literature demonstrates that survival percentages are
From the Departments of *Emergency Medicine, and †Pediatrics, Augusta
University Medical College of Georgia Augusta; and ‡Augusta University
Libraries, Robert B. Greenblatt, M.D. Library Augusta, GA.
Disclosure: The authors declare no conflicts of interest.
Reprints: Larry B. Mellick, MS, MD, FAAP, FACEP, Department of Emergency
Medicine, Augusta University Medical Center, 1120 15th St, Augusta, GA
30912 (e‐mail: lmellick@augusta.edu).
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.pec-online.com).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2017
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
significant even past 24 hours of torsion. This information should encour-
age aggressive management of patients presenting with TT pain that has
been ongoing for many hours.
Key Words: spermatic cord torsion, testicular torsion, testicle torsion,
torsed testicle, orchiectomy, orchiopexy
(Pediatr Emer Care 2017;00: 00–00)
CASE
A 17-year-old African American adolescent boy presented to
the pediatric emergency department approximately 3 days after
the onset of his right scrotal pain. The patient reported that his pain
was constantly 8 of 10 in severity and that for several days he did
not tell his mother because he was scared, embarrassed, and
hoping that the pain and swelling would resolve. The patient
was taken to surgery approximately 70 hours after the onset of his
testicular torsion (TT). At the time of surgical exploration, a bell
clapper deformity was noted, and the testicle was noted to be cy-
anotic and torsed 360 degrees. Although the left testicle was ex-
plored and orchiopexy performed, the previously torsed right
testicle “pinked up.” Consequently, the right testicle was returned
to the scrotum, and orchiopexy was performed. During a telephone
call approximately 1 week after the surgery, the patient stated that
he was experiencing no pain, and that his testicle seemed to be
completely back to normal.
Commonly reported time limits for testicle survival after the
onset of a TT event is 6 to 8 hours. However, clinical experience
suggests that some testicles survive well beyond these described
time frames; although some degree of atrophy often occurs as
the duration of torsion progresses. Our primary research questions
were the following: (1) for patients with TT, what are the rates of
organ survival with either manual or surgical intervention? (2) For
patients with TT, what is the relationship between time to treat-
ment and testicle survival? This article began as a simple review
of the literature and after searching hundreds of articles using
PubMed and manual searches, a decision was made to change
the article to a systematic review. The inclusion criteria for our
systematic review was to find all English, available full text arti-
cles that provided observational data of TT patients (6 months
through adulthood) from retrospective, prospective, chart reviews,
systematic reviews, and case series. Articles excluded from the
review included non-English articles, opinion articles, editorials,
animal studies, case series of undescended testicles, and neonatal
cases or children under 6 months of age.
METHODS
The systematic review was performed with the assistance of
a librarian from our university library. The databases searched in-
cluded PubMed (from 1966 to April 2017), Cochrane Library,
Ovid MEDLINE (from 1946 to April 2017), Web of Science,
and ProQuest Theses and Dissertations. The TT search resulted
in 1098 articles, and the search with time search terms added
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Mellick et al
resulted in 261 articles for a total of 1359 articles. Examples of
search strategies used for the systematic review can be viewed in
(Appendix 1, http://links.lww.com/PEC/A207). There were 686
articles for review after duplicates and 109 foreign language arti-
cles were removed. The total records screened in the systematic
review were 686. Of these, 196 full-text articles were assessed for
eligibility, and 179 articles were subsequently excluded for various
reasons. A total of 17 studies were included from the systematic
review and 13 studies from hand searching the literature, which
accounted for a total of 30 articles that met our inclusion criteria
(Fig. 1). An evidence table was not created for this systematic
review because all 30 articles were case series, level 4 evidence,1
and all had nearly identical limitations and potentials for bias.
From these 30 studies, data extraction was performed. Because
of significant variation in reporting, it was necessary to develop 3
different reporting groups. Included in each of these 3 groups were
articles with similar time formats for reporting hours until testicle
survival or death. The largest group, Group I, included articles that
reported testicle survival outcomes in 6-hour time segments until
after 24 hours when 24-hour time frames were used. Group II in-
cluded articles that reported survival in 6-hour time frames until
13 hours when reporting was for 13 to 24 hours and then subse-
quently 24-hour time frames. Group III included the smallest
number of articles (4), and data were reported in 12-hour time seg-
ments until after 24 hours when 24-hour time frames were used.
Moreover, because of overlap in survival reporting time frames
FIGURE 1. PRISMA flow diagram of literature search and selection of studies.32
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Pediatric Emergency Care • Volume 00, Number 00, Month 2017
between the 3 groups, we were able to create several cumulative
survival reports (Table 1).
RESULTS
Thirty studies relevant to answering the research question
were discovered during our searches.2–31 Seventeen studies were
found as part of the systematic review. Thirteen studies were dis-
covered through the manual search of PubMed, which occurred
before beginning the systematic review. A total of 2116 TT pa-
tients with information regarding survival outcomes were in-
cluded in this study. Seventeen studies including 1327 patients
(Group I) presented their data in 6-hour intervals of time since on-
set of symptoms out to 24 hours, and then 2 additional time frames
of 25 to 48 hours, and greater than 48 hours, respectively. Another
9 studies included 418 patients (Group II) and likewise used
6-hour reporting intervals from time of onset, but then grouped
patients together presenting between 13 to 24 hours. Similarly, this
second group of 9 studies also reported viability in 2 additional
groups at 25 to 48 hours and at greater than 48 hours. In a third
and smaller group of studies (Group III) that included 4 studies
with 371 patients, survival was reported at 0 to 12 hours, 13 to
24 hours, and greater than 24 hours. In Group I, 2 studies (Allan
and Osegbe) varied at 25 hours.4,8 These 2 studies only reported
survival after 25 hours and did not use the 25 to 48 hours and
greater than 48 hours time frames. Consequently, these numbers
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Pediatric Emergency Care • Volume 00, Number 00, Month 2017 Testicle Survival Time After a Torsion Event

TABLE 1. Testicle Survival (or Death) According to Time in Hours From Onset of the Torsion Event

Group I
Author (year) 0–6 h 7–12 h 13–18 h 19–24 h 25–48 h >48 h Total
Walton (1952) 3 (0) 1 (0) 0 (1) 0 (1) 0 (4) 10
Jones (1962) 1 (0) 3 (0) 2 (5) 11
Allan (1966) 4 (0) 4 (3) 5 (8) 1 (6) 0 (19)* 50
Sparks (1971) 5 (0) 1 (0) 1 (0) 0 (1) 0 (1) 2 (2) 13
Greaney (1975) 11 (0) 1 (1) 2 (2) 17
Williamson (1976) 87 (3) 21 (11) 7 (5) 7 (7) 3 (27) 0 (62) 240
Osegbe (1981) 4 (2) 3 (1) 1 (0) 2 (1) 3 (22)* 39
Cattolica (1982) 8 (0) 2 (1) 1 (1) 1 (1) 1 (1) 1 (9) 27
Veeraraghavan (1982) 29 (2) 11 (1) 4 (0) 8 (1) 6 (0) 0 (13) 75
Anderson (1988) 222 (4) 89 (10) 19 (8) 28 (30) 16 (46) 12 (140) 624
Magoha (1989) 15 (0) 7 (10) 1 (4) 1 (7) 1 (15) 1 (19) 81
Hastie (1990) 10 (1) 4 (0) 3 (0) 0 (2) 0 (1) 21
Lewis (1995) 9 (1) 4 (4) 1 (0) 3 (4) 0 (10) 36
Corbett (2002) 10 (0) 5 (0) 2 (1) 1 (1) 0 (3) 23
Watanabe (2007) 4 (0) 0 (1) 0 (1) 0 (5) 0 (3) 14
Njeze (2012) 9 (0) 1 (0) 1 (0) 1 (4) 16
Barrio (2014) 14 (0) 9 (0) 0 (3) 0 (1) 1 (2) 30
Percent Survival 445/458 = 97.2% 165/208 = 79.3% 46/75 = 61.3% 48/113 = 42.5% 32/131 = 24.4% 22/298 = 7.4% 1327 [1283]†
Group II
Author (year) 0–6 h 7–12 h 13–24 h 25–48 h >48 h Total
Barker (1964) 3 (1) 3 (0) 4 (0) 3 (3) 5 (13) 35
Macnicol (1974) 10 (0) 6 (0) 4 (8) 3 (11)‡ 42
Cass (1980) 15 (0) 9 (0) 5 (0) 4 (0) 2 (4) 39
Koh (1995) 11 (3) 2 (1) 3 (0) 4 (4) 5 (18) 51
Mushtaq (2003) 14 (2) 9 (1) 3 (2) 2 (7)‡ 40
Mäkelä (2007) 36 (0) 8 (8) 1 (22) 0 (25)‡ 100
Rouzrokh (2015) 16 (6) 13 (11) 7 (5) 8 (4)‡ 70
Saad (2015) 0 (0) 4 (0) 5 (1) 1 (2) 0 (13) 26
Ugwumba (2016) 1 (0) 5 (0) 2 (0) 1 (1) 1 (4) 15
Percent Survival 106/118 = 89.8% 59/80 = 73.8% 34/72 = 47.2% 13/23 = 56.5% 13/65 = 20.0% 418 [358]†
Cumulative I and II 551/576 = 95.7% 224/288 = 77.8% 128/260 = 49.2% 45/154 = 29.2% 35/363 = 9.6%
Group III
Author (year) 0–12 h 13–24 h 25–48 h >48 h Total
Wright (1977) 17 (0) 4 (2) 1 (1)§ 4 (12)§ 41
Shukla (1983) 19 (1) 10 (3) 3 (5)§ 0 (5)§ 46
Knight (1984) 43 (3)|| 5 (7) 4 (43) 105
Jones (1986) 77 (6) 27 (4) 30 (35) 179
Percent survival 156/166 = 94% 46/62 = 74.2% 42/143 = 29.4% 371
Total patients 2116
Cumulative I, II, and III 0–12 h 13–24 h >24 h
Percent survival 931/1030 = 90.4% 174/322 = 54.0% 138/764 = 18.1%
*Reported only >24 hours, data omitted from Group 1 tally and percentage calculations but used in cumulative tally for Groups I, II, and III.
†
Totals in parentheses do not include the patients for those timeframes with variance in reporting.
‡
Reported only >24 hours, data omitted from Group II tally and percentage calculations but used in cumulative tally for Groups I, II, and III.
§
Reported 24 to 48 hours and >48 hours survival data. These numbers were combined and presented as data for >24 hours for Group III.
||
Reported survival for the first 12 hours in three 4-hour intervals. The data in the three 4-hour sets were combined and reported as 0 to 12 hours survival.

were not used in the tallies for those time frames. Similarly in Group
II, 4 studies did not use the 24 to 48 hours and greater than 48 hours
time frames. Again, these patients were not included in the patient
tally for those time frames. However, these previously omitted
numbers in Groups I and II were used in reporting cumulative
numbers for 0 to 12 hours, 13 to 24 hours, and greater than 24 hours
time frames from all 3 groups. Finally, 2 other variations in time
frame reporting for Group III occurred. First, because Knight et al
reported their survival for the first 12 hours in three 4-hour inter-
vals, we took the liberty of simply reporting the 4-hour sets as

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Mellick et al
survival in 0 to 12 hours.30 Second, Wright and Shukla28,29 re-
ported 25 to 48 hours and greater than 48 hours in their data. We
again combined reported patients into the encompassing greater
than 24-hour time frame used in Group III reporting. In addition
to combining and reporting cumulative data for all 3 groups, cumu-
lative data for Groups I and II were also tallied and reported.
Consistent with traditional teaching, survival was greatest if
the patient presented within 0 to 6 hours of symptom onset and
was managed surgically in a timely fashion. For Group 1, the sur-
vival rate at 0 to 6 hours was 97.2%; at 7 to 12 hours, 79.3%; at
13 to 18 hours, 61.3%; at 19 to 24 hours, 42.5%; at 25 to 48 hours,
24.4%; and at greater than 48 hours survival, 7.4%. For Group II, the
survival rate at 0 to 6 hours was 89.8%; at 7 to 12 hours, 73.8%; at
13 to 24 hours, 47.2%; at 25 to 48 hours, 56.5%; and for greater
than 48 hours, 20.0%. The cumulative survival rate for manage-
ment within this 0- to 6-hour period for Groups I and II (576 pa-
tients) was 95.7%. The cumulative salvage rate for Groups I and II
for management within 7 to 12 hours (288 patients) was 77.8%;
for 13 to 24 hours (260 patients), 49.2%; for 25 to 48 hours (154 pa-
tients), 29.2%; and for greater than 48 hours (363 patients), 9.6%.
The 4 studies in Group III included 371 patients and reported a sur-
vival rate of 94.0% at 0 to 12 hours, 74.2% at 13 to 24 hours, and
29.4% at greater than 24 hours. Cumulative data from all 3 groups
using the Group III time frames and including all 2116 patients were
90.4% survival at 0 to 12 hours, 54.0% survival from 13 to 24 hours,
and 18.1% survival at greater than 24 hours.
LIMITATIONS
Despite attempts at performing exhaustive searches both
manually and through the systematic review process, it is probable
that this report did not find every applicable case series describing
useful survival time frames from TT. In addition, the studies in-
cluded were mostly retrospective in design and vulnerable to the
weaknesses and biases inherent in retrospective reviews. Never-
theless, the 30 articles we did find included several thousand pa-
tients and our data provide the reader with valuable information
that allows for a better understanding of testicular survival after
a torsion event.
We would note, however, that intermittent torsion of the tes-
ticle was not included in this discussion even though this condi-
tion may be responsible for some prolonged periods of survival.
The frequency of occurrence and contribution of intermittent
torsion is unknown, but should be acknowledged.
Moreover, just as prolonged survival may have other expla-
nations, necrosis in less than 2 to 6 hours is seemingly inconsistent
with known pathophysiology of tissue ischemia and would sug-
gest other explanations such as errors in historical documentation
or delayed recognition by the patient secondary to an atypical
painless presentation.
Finally, as described in our Methods section, there was occa-
sional variation in reporting survival after 24 or 48 hours. More-
over, several papers presented their salvage rates in graphical
format requiring careful extrapolation of data and a very limited
number required accounting for referenced numbers of case
subsets within the total number of subjects reported.
DISCUSSION
Our review of the literature confirms that testicular survival
after torsion is quite variable, and that significant numbers of
testes can survive even after 24 hours or longer of apparent tor-
sion. Although it should be acknowledged that the incidence of
testicular atrophy and compromised function will increase with
duration of torsion, the apparent survival of the testicle was the
focus of this review.
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Pediatric Emergency Care • Volume 00, Number 00, Month 2017
Interestingly, in 2003, Visser and Heyns33 graphically reported
salvage and atrophy from 2 meta-analyses with 1140 patients in
22 studies and with 535 patients in 8 other reports, respectively.
His article, unfortunately, did not include references for the arti-
cles used in his meta-analyses. Nevertheless, extracting data from
the graph of Visser and Heyns, which demonstrated the percent-
age of survivors within reported 6-hour time intervals, yielded
numbers remarkably similar to our own findings. The survival
numbers as graphed were approximately 96% survival at 6 hours,
82% survival at 12 hours, 60% at 18 hours, 46% at 19 to 24 hours,
20% at 25 to 30 hours, and 7% survival at >48 hours. Our Group I
tallied survivals and time frames used are almost identical to
those reported graphically by Visser and Heyns33 (Table 1). The
similarities seem to mutually support the validity of our respective
systematic reviews.
In our literature review, we did not attempt to extract data
concerning atrophy after TT. The data available and reporting
was considered too heterogeneous to allow the collection of
meaningful cumulative data on atrophy after testicular salvage.
However, in a large study of 537 TT patients by Anderson and
Williamson,11 atrophy in testicles viable at the time of operation
was 0% at 0 to 6 hours, 1% at 7 to 12 hours, 15.8% at 13 to
18 hours, 35.7% at 19 to 24 hours, 81.3% at 25 to 48 hours, and
66.7% in the small number surviving greater than 48 hours. Visser
and Heyns also graphically reported on atrophy data from the
2 meta-analyses reported previously. Atrophy was approxi-
mately 2% for surviving testicles surgically managed between
1 to 6 hours, 8% at 6 to 12 hours, just over 40% at 12 to 24 hours,
and just under 80% at greater than 24 hours.33
CONCLUSION
In conclusion, testicular survival after a torsion event can be
expected after longer periods of torsion than commonly recog-
nized and traditionally taught. This information will potentially
discourage therapeutic nihilism when torsion pain has lasted
longer than 6 to 8 hours. Testicular atrophy can be expected to
increase the longer therapeutic interventions are delayed, with
associated effects on function and size. However, it also seems
to be the case that many testicles will demonstrate minimal signs
of injury even after prolonged periods of torsion. Awareness
of this potential for survival even after prolonged torsion is
critical so as to ensure continued efforts toward timely organ
preserving interventions.
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