Orchiopexy After Testicular Torsion: Why Both Testicles May Need Fixation

Testicular torsion is one of those medical emergencies where time matters more than almost anything else. It usually begins suddenly, often with severe pain in one testicle, swelling, nausea, vomiting, or a testicle that seems to sit higher than usual. For a teenager, young adult, or parent watching a child in pain, it can be frightening and confusing. But the key point is simple: suspected testicular torsion should be treated as an emergency until proven otherwise.

The standard treatment is surgery. This surgery is commonly called orchiopexy or orchidopexy. In testicular torsion, the surgeon untwists the affected testicle, checks whether blood flow returns, and then fixes the testicle to the inside of the scrotum so it cannot twist again. In many cases, the surgeon also fixes the other testicle during the same operation. Mayo Clinic explains that surgery for testicular torsion involves making a small cut in the scrotum, untwisting the spermatic cord when needed, and stitching one or both testicles to the inside of the scrotum. (Mayo Clinic)

This often surprises patients and parents. If only one testicle twisted, why does the other side need surgery? The answer lies in the anatomy that causes torsion in the first place. Many people who develop testicular torsion have a structural tendency that allows the testicle to swing and rotate too freely inside the scrotum. If that tendency is present on one side, the other testicle may be at risk too. Cleveland Clinic describes the “bell clapper” deformity as the main cause of testicular torsion, where the testicle can swing freely in the scrotum and twist the spermatic cord.  (Cleveland Clinic)

Orchiopexy after testicular torsion is an emergency operation performed to save the twisted testicle and prevent future twisting. It is different from orchiopexy for an undescended testicle. In undescended testicle surgery, the goal is to move a testicle into the scrotum. In torsion surgery, the testicle is already in the scrotum, but it has twisted around its own blood supply.

The spermatic cord carries blood vessels, nerves, and the tube that transports sperm. When the cord twists, blood flow to the testicle is reduced or blocked. If this continues too long, the testicle can become permanently damaged. Cleveland Clinic notes that testicular torsion cuts off blood flow to the testicle and requires surgery, with the testicle sometimes needing removal if treatment is not received quickly. (Cleveland Clinic)

During orchiopexy for torsion, the surgeon usually opens the scrotum, untwists the affected testicle, evaluates its color and blood supply, and waits to see whether it improves. If the testicle appears viable, it is secured inside the scrotum using stitches. If it is too badly damaged and cannot recover, the surgeon may remove it, a procedure called orchiectomy or orchidectomy. Guy’s and St Thomas’ NHS Foundation Trust explains that if the twisted testicle is healthy, it can be stitched to stop future twisting, and the other testicle is stitched in the same way to prevent torsion on that side. (Guy’s and St Thomas’ NHS Trust)

The urgency of testicular torsion comes from the testicle’s dependence on blood flow. Once the spermatic cord twists, oxygen-rich blood cannot reach the testicle properly. The longer blood flow remains blocked, the lower the chance of saving the testicle.

A clinical review on testicular torsion outcomes reported that testicular salvage rates are over 90 percent when surgical exploration is performed within 6 hours of symptom onset, fall to about 50 percent when symptoms last beyond 12 hours, and drop below 10 percent after symptoms have been present for more than 24 hours. (PMC)

That is why sudden testicular pain should never be ignored. It is not something to “sleep on,” massage, treat with painkillers, or wait to discuss during a routine appointment. Even if the pain improves, the patient still needs urgent assessment because intermittent twisting and untwisting can happen.

Mayo Clinic also notes that manual detorsion, where a doctor tries to untwist the testicle by hand, may sometimes be attempted, but surgery is still needed to prevent torsion from happening again. (Mayo Clinic) 

The biggest reason surgeons often fix both testicles is that the problem may not be limited to the painful side. In many patients, torsion happens because the testicle is not firmly attached inside the scrotum. This allows it to rotate like a bell clapper inside a bell, which is why the anatomy is commonly called a bell clapper deformity.

If the same loose attachment exists on the opposite side, that testicle may also twist in the future. Because torsion can threaten testicle survival within hours, surgeons often prefer to prevent a second emergency while the patient is already under anesthesia.

The Finding Consensus for Orchidopexy in Torsion study describes emergency scrotal exploration as the gold standard for testicular torsion and states that when the testicle is viable after untwisting, it is fixed, usually along with the opposite testicle. (PMC)  Guy’s and St Thomas’ NHS guidance gives the same practical explanation: the healthy twisted testicle is stitched to prevent twisting again, and the other testicle is stitched in the same way to prevent torsion on that side. (Guy’s and St Thomas’ NHS Trust)

This does not mean that both testicles are diseased. It means the other side may share the same anatomical risk. Fixing it is a preventive step.

The exact steps may vary depending on the patient’s age, the time since pain began, and what the surgeon finds during exploration. However, the general sequence is usually similar.

First, the patient is given anesthesia. Testicular torsion surgery is typically done urgently, often under general anesthesia. The surgeon then makes an incision in the scrotum to reach the affected testicle. If the spermatic cord is twisted, it is carefully untwisted. Blood flow is then assessed.

A testicle that has been deprived of blood may look dark, blue, or unhealthy at first. Sometimes, after untwisting and warming, the testicle begins to regain a healthier color. If the surgeon believes it can recover, orchiopexy is performed. This means the testicle is anchored to the inner wall of the scrotum with stitches.

Cleveland Clinic describes orchiopexy for torsion as a procedure in which the surgeon untwists the testicle and secures it to the inside of the scrotum. (Cleveland Clinic)  If the affected testicle is not viable, it may be removed, and the opposite testicle is still usually fixed to reduce the risk of torsion on the remaining side. Guy’s and St Thomas’ NHS also explains that if the twisted testicle is too damaged to recover, it may need to be removed, while the other testicle is stitched to prevent twisting.  (Guy’s and St Thomas’ NHS Trust)

In many confirmed torsion cases, yes, both testicles are fixed. However, the decision depends on what the surgeon finds. If torsion is confirmed, the opposite side is commonly fixed because of the risk of a similar anatomical problem. If torsion is not found and the testicles look normal, the surgeon may decide that fixation of the other side is not needed.

Guy’s and St Thomas’ NHS notes that sometimes, during surgery, the doctor finds that the testicle is not actually twisted, and there may be no need to operate on the other testicle. (Guy’s and St Thomas’ NHS Trust)

In real-world practice, the surgeon’s judgment matters. If the symptoms strongly suggest torsion or the anatomy appears risky, fixation may still be considered even if the testicle has untwisted by the time of surgery.

Not every torsion episode presents as continuous severe pain. Some patients have intermittent testicular torsion, where the testicle twists and then untwists on its own. Pain may come suddenly, last minutes or hours, and then improve. This can be misleading because the patient may feel normal by the time they reach a doctor.

Intermittent torsion is still important because it may be a warning sign before a more severe episode. A 2024 study on bilateral orchiopexy for intermittent testicular torsion concluded that elective bilateral orchiopexy prevented torsion and preserved testicular viability, although pain did not resolve in every patient. (PMC)

For patients with repeated episodes of sudden testicular pain, especially if the testicle changes position during attacks, a urologist may discuss planned orchiopexy even if the emergency has passed.

Orchiopexy is done to prevent recurrence, and recurrence is uncommon. However, it is not impossible. This is important because some patients and even clinicians may assume that torsion cannot happen again once the testicle has been fixed.

A review on recurrent testicular torsion after previous orchiopexy states that recurrent torsion is rare but can happen, and it may present with similar symptoms to the first episode. (PMC) Another case-based review emphasized that recurrent torsion after previous orchiopexy requires a high index of suspicion to avoid missed diagnosis and delayed management. (PMC)

The practical message is straightforward: new sudden testicular pain after orchiopexy still needs urgent medical attention. A past orchiopexy lowers the risk but does not give a lifelong guarantee against every possible twist, especially if the earlier fixation loosens, fails, or was done with a technique that did not fully prevent rotation.

Recovery depends on whether the testicle was saved, whether one testicle was removed, the patient’s age, and how inflamed or swollen the scrotum was before surgery. In general, pain and swelling are expected for several days.

Alberta Health’s aftercare guidance for orchiopexy for testicle torsion states that mild to moderate pain may last for several days, scrotal swelling is normal, and swelling usually goes down within 2 to 4 weeks. It also notes that most normal activities can often be resumed after 1 to 2 weeks, except activities requiring heavy effort.  (MyHealth Alberta)

Cleveland Clinic’s testicular torsion guidance says pain should decrease after about a week, return to school or work may be possible around that time, and return to physical activity may take up to two weeks.  (Cleveland Clinic)

During recovery, patients are usually advised to avoid heavy lifting, cycling, running, contact sports, gym workouts, and sexual activity until cleared by the surgeon. Supportive underwear may help reduce discomfort. Pain medicine should be taken only as advised by the treating doctor.

Some swelling, bruising, and soreness are expected after scrotal surgery. However, certain symptoms should prompt urgent contact with the surgeon or emergency department.

Patients should seek medical advice if they develop fever, worsening pain, increasing redness, pus or foul-smelling drainage, heavy bleeding, severe swelling, difficulty passing urine, persistent vomiting, or sudden return of severe testicular pain. Alberta Health’s aftercare guidance specifically highlights calling for help if pain worsens, there is new or worse swelling, bleeding soaks through the bandage, signs of infection appear, or the patient cannot pass urine. (MyHealth Alberta)

The most important warning sign is sudden severe testicular pain, even after surgery. It should not be dismissed just because orchiopexy has already been done.

Fertility after testicular torsion depends on several factors: how long the testicle was twisted, whether it was saved, how much injury occurred before surgery, whether the opposite testicle is healthy, and whether there were previous testicular problems.

If the affected testicle is saved quickly and the other testicle is normal, many patients do well. However, torsion can still affect sperm production in some cases. If one testicle must be removed, the remaining testicle often continues to produce testosterone and sperm. Cancer Research UK explains that after removal of one testicle, the remaining testicle usually makes more testosterone and sperm to compensate, although fertility may be reduced in some people if the remaining testicle does not work well. (Cancer Research UK)

For teenagers and adults who are worried about fertility, it is reasonable to ask the urologist whether semen analysis is needed later, especially if there are concerns about future fatherhood, history of both-sided testicular problems, or removal of one testicle.

Most patients who keep at least one healthy testicle maintain normal testosterone production and normal sexual development or sexual function. Problems are more likely if both testicles are severely damaged, if one testicle was already abnormal, or if there are separate hormonal issues.

Cleveland Clinic notes that people who have both testicles removed cannot produce sperm and become infertile. (Cleveland Clinic) This situation is very different from the more common case of one-sided torsion, where the other testicle is healthy and fixed to prevent future twisting.

For adolescents, parents should also remember the emotional side. Sudden testicular pain, emergency surgery, fear of losing a testicle, and embarrassment around genital symptoms can all be stressful. Clear, calm explanation and follow-up with a urologist can make recovery easier.

If the twisted testicle is too badly damaged, the surgeon may remove it. This can be upsetting, but it is sometimes necessary when the testicle is no longer viable. The goal is to prevent ongoing pain, infection risk, and complications from dead tissue.

The other testicle is usually fixed during the same operation to reduce the risk of losing the remaining testicle to future torsion. Later, the patient may discuss a testicular prosthesis if appearance is a concern. This is usually a personal decision and may be considered at a suitable age depending on the patient’s preference and surgeon’s advice.

Emotionally, losing a testicle can feel bigger than the physical change itself. Many patients worry about masculinity, sexual function, fertility, or body image. A supportive discussion with the urologist is important, especially for teenagers.

After the emergency is over, patients and parents often have many questions. Useful questions include:

Was the testicle fully twisted, partially twisted, or already untwisted by the time of surgery?

Was the affected testicle healthy enough to save?

Were both testicles fixed?

What type of stitches were used?

How long should sports, cycling, gym activity, and sexual activity be avoided?

When should follow-up be scheduled?

Is there any concern about testicular shrinkage?

Should fertility testing be considered later?

What symptoms should trigger urgent review?

These questions help convert a frightening emergency into a clear recovery plan.

Follow-up is important after orchiopexy. The doctor may check whether the saved testicle remains in position, whether swelling has settled, and whether the testicle appears to be maintaining size. In some cases, an ultrasound may be used later if there is concern about blood flow, shrinkage, or ongoing pain.

Patients should also learn to report new lumps, swelling, heaviness, or persistent discomfort. While torsion is not the same as cancer, awareness of testicular health is important for all adolescents and adults.

For younger boys, parents should attend all follow-up appointments and ask when the child can safely return to school, sports, swimming, and normal physical activities. For teenagers, privacy and reassurance matter. They should understand that sudden testicular pain in the future is still an emergency, even if they have already had surgery.

Orchiopexy after testicular torsion is done for two reasons: to save the twisted testicle if possible and to prevent torsion from happening again. In many confirmed cases, surgeons fix both testicles because the anatomical problem that allows one testicle to twist may also be present on the other side.

This is why a patient may go into surgery with pain on one side and come out with both testicles fixed. It is not unnecessary extra surgery. It is often a preventive step designed to protect the other testicle from a future emergency.

The most important thing to remember is that testicular torsion is time-sensitive. Sudden severe testicular pain, swelling, nausea, vomiting, or a high-riding testicle needs immediate medical attention. Early surgery offers the best chance of saving the testicle. Delayed treatment can lead to permanent damage or removal.

For patients who have already had orchiopexy, recovery is usually manageable, but follow-up matters. Pain should gradually improve, swelling should settle, and normal activities should resume only when the surgeon allows. Most importantly, any new sudden testicular pain after surgery should still be treated seriously.

Medical note: This article is for educational purposes only and should not replace emergency care, diagnosis, or treatment from a qualified doctor or urologist. Suspected testicular torsion should be treated as a medical emergency.