Are we still too late to preserve the testes? A global survey of delayed consultation and risk factors for testicular torsion: a systematic review and meta-analysis

Background: Testicular torsion (TT) is a urological emergency that requires prompt diagnosis and urgent surgical intervention. Delayed presentation is strongly associated with testicular loss and long-term atrophy. Objective: To systematically assess global trends in delayed consultation and mean symptom duration (MSD) in TT and to identify associated risk factors. Methods: A systematic review and meta-analysis of studies (1970-2025) that reported delayed consultation rates, MSD, orchiectomy rates, misdiagnosis, and patient transfers (PROSPERO: CRD420251155132). Results: A total of 176 studies from 45 countries (100,166 cases) were included in this study, of which 15 (5,221 cases) analyzed delayed consultation and 14 (1,513 cases) analyzed MSD. The consultation rate within 6 h ranged from 14.29% to 72.58%, whereas MSD ranged from 4.35 to 107.45 h. Pooled risk ratios (RRs) indicated that abdominal pain reduced the risk of delayed for >6 h [RR 0.91, 95% CI 0.68-1.21] but increased the risk for >12 h [1.19, 1.04-1.37] and >24 h [1.05, 0.77-1.43], while hydrocele decreased [>12 h [0.69, 0.47-1.02], >24 h [0.56, 0.34-0.92]]. Misdiagnosis [>12 h [1.52, 1.27-1.83], >24 h [1.10, 0.63-1.92]] and first visit to primary or secondary care unit [>12 h [1.29, 0.96-1.74], >24 h [1.36, 0.98-1.91]] significantly increased the risk. Transfer was protective and associated with lower odds of prolonged delays [>6 h [0.74, 0.50-1.08], >24 h [0.63, 0.44-0.90]]. A comparative meta-analysis of MSD demonstrated longer durations during the pandemic (SMD -0.37; 95% CI: -0.59, -0.14) in patients without manual detorsion (-0.70; -1.03, -0.37) and in patients misdiagnosed (2.36; 0.34, 4.38). Transfer from other hospitals was associated with shorter durations (-0.42; -0.60, -0.23). Conclusions: Delayed presentation remains widespread with notable regional disparities. Symptoms, healthcare pathways, misdiagnosis, and public health crises affect timely care. Improved awareness, optimized referral pathways, and strengthened emergency access are essential to minimize testicular loss. Systematic Review Registration: identifier CRD420251155132.