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Difficulty: MediumUrologic Surgery

During a high school basketball game, a 1616-year-old adolescent boy suddenly experiences excruciating left-sided scrotal pain and collapses on the court. He is immediately transported to the hospital by his coach. The patient reports severe, unrelenting pain radiating to his lower abdomen and has vomited twice in the triage area. He is otherwise healthy and takes no medications. Vital signs show a temperature of 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), blood pressure of 130/85 mm Hg130/85\text{ mm Hg}, and a pulse of 110/min110/\text{min}. Physical examination reveals a swollen, exquisitely tender left hemiscrotum. The left testicle is firm, positioned higher than the right, and lies in a transverse orientation. The cremasteric reflex is absent on the left side but intact on the right. There is no relief of pain upon manual elevation of the scrotum. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Color Doppler ultrasonography of the scrotum
  2. B
    Intramuscular ceftriaxone and oral doxycycline
  3. Immediate surgical explorationAnswer
  4. D
    Scrotal elevation and nonsteroidal anti-inflammatory drugs
  5. E
    Urinalysis and urine culture

Answer

Immediate surgical exploration
The correct answer is immediate surgical exploration. This patient presents with a classic presentation of testicular torsion: abrupt onset of severe scrotal pain, nausea, an absent cremasteric reflex, and a high-riding, transversely oriented testicle. Testicular torsion is a urologic emergency caused by the twisting of the spermatic cord, which compromises blood flow and leads to ischemia. Testicular salvage is highly time-dependent, with the best outcomes achieved if surgical detorsion and bilateral orchiopexy are performed within 6 hours of symptom onset. When the clinical suspicion is high based on classic history and physical exam findings, the patient should be taken immediately to the operating room. Delaying surgery to perform diagnostic testing, such as Doppler ultrasonography, is contraindicated as it increases the risk of irreversible testicular necrosis.

Step-by-Step Solution

1
Identify the primary clinical presentation.
Sudden onset severe scrotal pain, nausea, absent cremasteric reflex, and a high-riding, transversely oriented testicle in a male adolescent.
To establish the most likely diagnosis based on hallmark clinical signs.
2
Formulate a diagnosis based on the clinical findings.
Testicular torsion.
The constellation of symptoms and classic physical exam signs strongly point to twisting of the spermatic cord, which leads to venous congestion and subsequent arterial compromise (ischemia).
3
Determine the most appropriate next step in management.
Immediate surgical exploration.
Testicular salvage rates decline rapidly after 4 to 6 hours of ischemia. Classic clinical signs warrant immediate surgery without delaying for confirmatory imaging.

Key Concept

Patients with a classic clinical presentation of testicular torsion (sudden severe pain, high-riding transverse testis, absent cremasteric reflex) require immediate surgical exploration and bilateral orchiopexy; imaging should not delay definitive treatment.
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Topics

Urologic Surgery

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