Scrotal pain and testicular torsion: Case

This boy has high-probability testicular torsion. The sudden severe unilateral pain that woke him from sleep, the vomiting, the high-riding horizontally lying testis, and the absent cremasteric reflex form the classic picture, and a TWIST score of 5 places him in the high-risk band. The 90-minute duration places him well inside the 6-hour salvage window, which makes the speed of the decision and the referral the determinant of whether he keeps his testis. [1]

Clinical findings and assessment

The key clinical findings are the absent cremasteric reflex on the right, the single most sensitive sign of torsion, the high-riding horizontal lie, the swelling and tenderness, and the vomiting. The clear urinalysis does not exclude torsion, and the cardinal signs do not fit a mimic. The TWIST score is 5, with one point each for the testicular swelling, the hard and tender testis, the absent cremasteric reflex, the vomiting, and the high-riding testis, which is the high-risk band confirmed by the systematic review and meta-analysis of Qin and Qu. [5]

The differential of the acute scrotum is short but high-stakes. Testicular torsion sits beside the torsion of the appendix testis, which is gradual and prepubertal with a blue dot sign and a normal lie, and the acute epididymitis, which is gradual with fever, dysuria, pyuria, and a preserved cremasteric reflex. The sudden severe onset, the absent cremasteric reflex, the high-riding testis, and the vomiting make torsion the working diagnosis, and the only safe stance is that torsion is present until excluded by exploration. [2]

Immediate management

The immediate management is to move this boy to theatre without imaging delay. I would make him nil by mouth, secure intravenous access, give weight-adjusted analgesia with paracetamol and an opioid for the severe pain, and call the surgeon the moment torsion is on the differential. The aim is theatre inside the 6-hour window, and the salvage rate is 90 to 100 percent when exploration occurs within 6 hours of pain onset, which is why a high-probability torsion goes straight to scrotal exploration and never waits for a scan. [1]

Colour Doppler ultrasound is reserved for the intermediate-risk boy with a TWIST score of 3 to 4, and it must never delay exploration in this high-probability presentation. If the surgeon is delayed, I would consider manual detorsion, rotating the testis laterally to open the book, as a painful bridge while awaiting theatre, but he would still proceed to definitive fixation. I would explain to the boy and his parents that the cord to the testis has twisted and cut off the blood supply, that the testis can be saved if it is untwisted quickly, and that he needs an urgent operation. [2]

Operation and long-term outcome

The operation is an urgent scrotal exploration under general anaesthesia. The scrotum is opened, the testis and the twisted cord are delivered, and the testis is detorsed by rotating it laterally to open the book. The testis is wrapped in warm saline and observed, and its viability is assessed by the return of a pink colour and by bleeding from an incision in the tunica albuginea. Because this boy is explored at 90 minutes, the testis is very likely viable, and it is fixed to the scrotal wall with non-absorbable sutures in an orchidopexy. [1]

The critical step performed in every case is the fixation of the contralateral testis, because the bell-clapper deformity is bilateral in about 12 percent of boys and a torsion on one side threatens the other. The boy is followed up for atrophy of the salvaged testis, because a prolonged torsion can leave some degree of atrophy despite a successful orchidopexy. The long-term fertility surveillance includes a semen analysis in adulthood, with referral to a fertility service if the parameters are abnormal, because the disruption of the blood-testis barrier can trigger antisperm antibody formation even after a salvage, as documented by Aggarwal and colleagues. [7]

The family is counselled honestly at every stage. They are told that the testis was untwisted and fixed in place so it cannot twist again, that the other side was fixed to protect it, and that he will be checked for fertility in the years ahead. A single healthy testis is usually sufficient for normal hormonal function and fertility, provided the semen parameters are preserved, and the boy is reassured and offered a prosthesis only if the testis had to be removed. The medicolegal principle is that a missed or delayed torsion is a lost testis, and a low threshold for exploration is the standard of care. [2]