Scrotal pain and testicular torsion: SAQ

This boy has high-probability testicular torsion. The sudden severe unilateral scrotal pain, the high-riding horizontally lying testis, the absent cremasteric reflex, and the vomiting form the classic picture, and the pain began only 70 minutes ago, which places him well inside the 6-hour salvage window. The clear urine does not exclude torsion, and the cardinal signs do not fit a mimic such as epididymitis or torsion of the appendix testis. The working diagnosis is torsion, and the priority is to move him to theatre without imaging delay. [1]

Question 1 (10 marks)

Outline your immediate assessment and management of this boy, including how you would use the TWIST score and how you would decide between theatre and imaging. [2]

I would state at the outset that this boy has torsion until proven otherwise, and I would record the exact time the pain began, because the salvage clock starts there. The assessment is a focused scrotal examination within minutes, confirming the high-riding horizontal testis and the absent cremasteric reflex, and I would examine the abdomen because referred abdominal pain from a hidden torsion is a classic trap. I would apply the TWIST score, which gives one point each for testicular swelling, a hard testis, an absent cremasteric reflex, nausea or vomiting, and a high-riding testis, for a maximum of five. This boy scores 5, with the swelling, the absent cremasteric reflex, the vomiting, and the high-riding testis, which is the high-risk band. [5]

A high-risk TWIST score means he goes straight to surgical exploration without imaging, and the systematic review and meta-analysis by Qin and Qu confirmed that high-risk boys should proceed to theatre. Colour Doppler ultrasound is reserved for the intermediate-risk boy with a score of 3 to 4, and it must never delay exploration in a high-probability presentation. I would make the boy 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. [2]

The aim is to have him in theatre inside the 6-hour window, and the salvage rate is 90 to 100 percent when exploration occurs within 6 hours of pain onset, falling to about 50 percent from 6 to 12 hours. 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. 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. [1]

Question 2 (10 marks)

Describe the operation for testicular torsion and the long-term follow-up and counselling, including the fertility and medicolegal considerations. [7]

The operation is an urgent scrotal exploration under general anaesthesia, ideally within 6 hours of pain onset. The scrotum is opened, the testis and the twisted cord are delivered, and the testis is detorsed by rotating it laterally, opening the book. The testis is then 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. A viable testis is fixed to the scrotal wall with non-absorbable sutures, which is the orchidopexy. [1]

A necrotic testis is removed by orchidectomy, and a prosthetic testis can be offered later in adolescence for cosmesis. The critical step performed in every case, whether the testis is salvaged or removed, 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 testicular atrophy despite a successful orchidopexy. [7]

The long-term fertility surveillance is part of the follow-up. After torsion, the disruption of the blood-testis barrier can trigger antisperm antibody formation, and Aggarwal and colleagues documented the long-term impact on semen parameters and gonadal function, so a salvaged boy, and especially a boy who had an orchidectomy, is offered a semen analysis in adulthood with referral to a fertility service if the parameters are abnormal. He is reassured that a single healthy testis is usually sufficient for normal hormonal function and fertility, provided the semen parameters are preserved. [7]

The medicolegal dimension is that a missed or delayed torsion is a lost testis and a preventable complaint. The standard of care is a low threshold for exploration, and a negative exploration in a boy who turns out to have a mimic is accepted and expected, because a senior clinician always prefers a negative exploration to a missed torsion. I would document the time of pain onset, the time of the decision, and the time of surgical referral, and I would communicate honestly with the family at every stage. [2]