Reproductive · Urologic Emergencies
The facts most likely to be tested
Testicular torsion is a surgical emergency caused by the twisting of the spermatic cord, leading to ischemic necrosis of the testis.
The classic anatomical predisposition is the bell-clapper deformity, characterized by the failure of the tunica vaginalis to properly anchor the testis to the posterior scrotum.
Patients typically present with acute, severe, unilateral scrotal pain often accompanied by nausea and vomiting.
Physical examination reveals a high-riding testis with a horizontal lie and an absent cremasteric reflex.
The Prehn sign—relief of pain with scrotal elevation—is classically negative in testicular torsion, helping to distinguish it from epididymitis.
The gold standard for diagnosis is color Doppler ultrasonography, which demonstrates decreased or absent blood flow to the affected testis.
Definitive management is emergent surgical detorsion and bilateral orchiopexy to prevent recurrence and preserve fertility.
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A 16-year-old male presents to the emergency department with a 3-hour history of sudden-onset, severe right-sided scrotal pain that began while playing soccer. He reports associated nausea. On physical exam, the right testis is tender, swollen, and positioned higher than the left, with a horizontal lie. The cremasteric reflex is absent on the right side, and elevation of the scrotum does not improve the pain.
What is the most appropriate next step in management?
Emergent surgical exploration
The clinical presentation is classic for testicular torsion; because this is a time-sensitive surgical emergency, one should not delay definitive treatment for imaging if the clinical suspicion is high.
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Etiology / Epidemiology
Bimodal distribution (neonates and puberty). Caused by bell-clapper deformity, a congenital failure of tunica vaginalis fixation.
Clinical Manifestations
Abrupt onset of unilateral scrotal pain. Pathognomonic: absent cremasteric reflex and Prehn sign negative.
Diagnosis
Gold standard is surgical exploration. Initial imaging of choice is scrotal ultrasound with Doppler showing absent blood flow.
Treatment
Emergent surgical orchiopexy. Do not delay surgery for imaging if clinical suspicion is high.
Prognosis
Time-sensitive; 90-100% salvage rate if detorsion occurs within 6 hours.
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Epidemiology & Etiology
Most common in adolescents aged 10-20 years. The bell-clapper deformity allows the testis to rotate freely within the tunica vaginalis. This congenital anatomical anomaly is the primary risk factor for intravaginal torsion.
Pertinent Anatomy
The tunica vaginalis normally attaches to the posterolateral aspect of the testis. In the bell-clapper deformity, this attachment is high, leaving the testis suspended like a clapper in a bell. This allows for intravaginal rotation of the spermatic cord.
Pathophysiology
Torsion of the spermatic cord leads to venous obstruction, followed by arterial occlusion. This results in testicular ischemia and infarction. The process is a surgical emergency requiring immediate detorsion to prevent permanent tissue necrosis.
Clinical Manifestations
Patients present with sudden, severe unilateral scrotal pain often radiating to the lower abdomen. Physical exam reveals a high-riding testis with a horizontal lie. The Prehn sign (relief of pain with elevation) is typically negative, and the cremasteric reflex is absent. Delayed treatment leads to testicular atrophy.
Diagnosis
Clinical diagnosis is paramount; do not delay for imaging if presentation is classic. Scrotal ultrasound with Doppler is the diagnostic test of choice, demonstrating decreased or absent blood flow. The definitive gold standard is surgical exploration.
Treatment
Immediate surgical detorsion and orchiopexy is required. If surgery is unavailable, manual detorsion (opening the book) may be attempted. Do not delay surgery for imaging if the clinical index of suspicion is high. Bilateral orchiopexy is performed to prevent future recurrence.
Prognosis
Salvage rates are >90% if performed within 6 hours. After 12-24 hours, the likelihood of testicular necrosis and subsequent atrophy approaches 100%.
Differential Diagnosis
Epididymitis: Prehn sign positive, gradual onset
Torsion of appendix testis: blue dot sign present
Inguinal hernia: bowel sounds in scrotum
Trauma: history of blunt force
Hydrocele: transilluminates on exam