Purpose of review <p>This review examines recent developments in the diagnosis of testicular torsion in the emergency setting, with an emphasis on clinical decision tools, performance characteristics of current diagnostic modalities, and key emerging technologies.</p> Recent findings <p>The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score remains a valuable clinical risk stratification tool, particularly at extreme values, although it does not fully exclude torsion at low scores. Point-of-care ultrasound (POCUS) has demonstrated high specificity and has been shown to significantly reduce time to surgical management compared to radiology-performed ultrasound. However, preserved intratesticular blood flow does not reliably rule out torsion, highlighting the importance of recognizing alternative sonographic findings such as the whirlpool sign. Emerging diagnostic modalities, including dual-wavelength optical devices, artificial intelligence–assisted ultrasound, and smartphone thermal imaging, show promising early results. In contrast, near-infrared spectroscopy currently lacks sufficient evidence to support routine clinical use.</p> Summary <p>Clinical evaluation remains central to the diagnosis of testicular torsion, although tools such as the TWIST score and POCUS can enhance decision-making and expedite treatment in the emergency department setting. The limitations of these modalities must be recognized to avoid missed cases. Novel technologies may offer more accessible and rapid alternatives for diagnosis, although additional research is needed to justify routine use of these modalities in clinical practice.</p>