Testicular torsion among adults: An extremely rare or an extremely under-estimated issue? A case report and a narrative review of the literature

Testicular torsion is an uncommon urological emergency, rare in men over 50 years of age. Its nonspecific clinical presentation often leads to misdiagnosis as more frequent conditions such as epididymo-orchitis, resulting in delayed treatment and poor testicular salvage outcomes. We report the case of a 54-year-old man presenting with right-sided scrotal pain and swelling, initially managed for epididymitis. Due to persistent symptoms despite antibiotic therapy, a scrotal ultrasound was performed, revealing absence of arterial blood flow in the right testis. Surgical exploration confirmed testicular necrosis secondary to a 720° spermatic cord torsion, necessitating right orchiectomy. A narrative literature review was also conducted via MEDLINE/PubMed and Scopus to identify relevant studies on adult testicular torsion: despite the narrative nature of our study, a reproducible approach has been adopted to identify the relevant studies for the final review. The Joanna Briggs Institute Checklist has been used to estimate the quality of the included articles. Nineteen studies were selected for inclusion after the selection process. The existing literature largely consists of anecdotal case reports and small case series, with most cases reporting delayed presentation and resulting orchiectomy. Unlike pediatric populations, where the clinical presentation is often more dramatic and recognizable, testicular torsion in adults may present more subtly, leading to misinterpretation and delays in surgical intervention. Late presentation to medical attention and reliance on conservative management strategies can delay the diagnosis of testicular torsion in adults. Although Doppler ultrasound serves as a helpful diagnostic adjunct, prompt surgical exploration remains essential when clinical suspicion is high. In conclusion, clinicians should maintain a high index of suspicion for testicular torsion in all patients presenting with acute scrotal pain, regardless of age. Early recognition and timely surgical intervention are crucial not only to preserve testicular viability but also to safeguard long-term physical, reproductive, and psychological health.