Testicular Torsion

A 21 year old male presents to the emergency department with sudden onset severe testicular pain that began 6 hours ago while playing basketball. The pain is acute, severe, and localized to the right testicle. He also reports nausea. On examination, the right hemiscrotum is swollen, erythematous, and tender. The cremasteric reflex is absent, which is highly suggestive of torsion. The affected testis may appear high-riding with a horizontal lie. Vital signs show blood pressure of 110/80 mm Hg, pulse rate of 88 beats per minute, respiratory rate of 16 breaths per minute, temperature of 96.7°F, and oxygen saturation of 98 percent on room air. Doppler ultrasonography shows absence of testicular blood flow. Diagnosis?

Diagnosis is Testicular Torsion.

1. Definition

Testicular torsion is a urological emergency caused by twisting of the spermatic cord, leading to testicular ischemia.

2. Etiology

1. Bell clapper deformity due to abnormal fixation of the testis to the tunica vaginalis
2. Leads to horizontal lie of the testis
3. Often triggered by physical activity or minor trauma

3. Pathophysiology

1. Twisting of the spermatic cord causes venous obstruction, followed by arterial compromise
2. Results in ischemia and potential infarction of the testis

4. Clinical Features

1. Sudden onset severe unilateral testicular pain
2. Scrotal swelling and erythema
3. Nausea and vomiting may be present
4. Absent cremasteric reflex
5. High-riding testis with horizontal lie

5. Diagnostic Evaluation

5.1 Clinical Diagnosis

1. Primarily a clinical diagnosis
2. Do not delay surgery for imaging if suspicion is high

5.2 Doppler Ultrasonography

1. Shows absent or reduced blood flow

6. Key Diagnostic Insight

Sudden testicular pain + absent cremasteric reflex = testicular torsion

7. Complications

1. Testicular infarction
2. Testicular atrophy
3. Infertility

8. Management

8.1 Emergency Management

1. Immediate surgical detorsion and bilateral orchiopexy

8.2 Time Sensitivity

1. Best outcomes if treated within 6 hours
2. Risk of irreversible damage increases after 6 to 12 hours

8.3 Manual Detorsion

1. May be attempted if surgery is not immediately available
2. Typically performed with medial to lateral rotation
3. Should not delay definitive surgical management

8.4 Non-viable Testis

1. Orchiectomy if the testis is not viable

9. Key Clinical Insight

Time is testis, early intervention is critical to salvage viability

10. Exam Level Pearls

1. Absent cremasteric reflex is highly suggestive
2. Bell clapper deformity is the underlying cause
3. Doppler shows absent blood flow
4. Always perform bilateral orchiopexy
5. Do not delay surgery in high clinical suspicion