Background: This study aimed to investigate the temporal evolution of ultrasound signs in patients with testicular torsion (TT) and correlate these delays with testicular salvageability and long-term reproductive outcomes. Methods: This retrospective study included 89 patients with TT treated from 2020 to 2025. Based on time from symptom onset to treatment, patients were divided into three groups: hyperacute (12 hours). We collected baseline data, ultrasound findings, testicular salvage rates, reproductive hormones levels and semen analysis. We used Spearman correlation and binary logistic regression to analyse the association of ultrasound features, and time windows, with the salvage rate. Results: The testicular salvage rates of the three groups were 96.8%, 62.1%, and 41.4%, respectively (p p p p = 0.011), whereas uneven testicular echogenicity (OR = 4.451, 95% CI: 1.257–15.763, p = 0.021), a positive whirlpool sign (OR = 4.445, 95% CI: 1.124–17.588, p = 0.033), and absent blood flow (OR = 4.446, 95% CI: 1.091–18.123, p = 0.037) were independent risk factors for salvage failure. The dynamic evolution of ultrasound findings provides an objective risk assessment basis for time sensitive stratified management of acute scrotum, supporting clinical grading and expedited intervention decisions. Conclusions: The 6-hour threshold may be a critical cutoff for both testicular survival and fertility preservation. For suspected torsion, surgical exploration should be prepared alongside ultrasound to minimize the time to treatment.
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