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Difficulty: MediumUrologic Surgery

A 15-year-old boy is brought to the emergency department by his parents due to the sudden onset of excruciating left-sided scrotal pain that woke him from sleep 3 hours ago. The pain is constant and accompanied by nausea and one episode of non-bilious emesis. He reports no dysuria, hematuria, urethral discharge, or recent flank pain. His temperature is 37.2∘C37.2^\circ\text{C} (99.0∘F99.0^\circ\text{F}), blood pressure is 128/82 mmHg128/82\text{ mmHg}, and heart rate is 110 /min110\text{ /min}. On physical examination, the left hemiscrotum is edematous, erythematous, and exquisitely tender to palpation. The left testicle is positioned higher than the right and lies horizontally. The cremasteric reflex is absent on the left side but intact on the right side. Which of the following is the most appropriate next step in management for this patient?

  1. Urgent operative detorsion and bilateral orchiopexyAnswer
  2. B
    Color Doppler ultrasonography of the scrotum
  3. C
    Intramuscular ceftriaxone and oral doxycycline
  4. D
    Scrotal elevation, ice packs, and oral ibuprofen
  5. E
    Midstream urinalysis and urine culture

Answer

Urgent operative detorsion and bilateral orchiopexy
The correct answer is urgent operative detorsion and bilateral orchiopexy. This patient's presentation—abrupt onset of severe scrotal pain waking him from sleep, accompanied by nausea, a high-riding and horizontally oriented testicle, and an absent cremasteric reflex—is highly characteristic of testicular torsion. Torsion typically occurs due to inadequate fixation of the lower pole of the testis to the tunica vaginalis (the "bell-clapper deformity"), which allows the spermatic cord to twist and occlude gonadal blood flow. Because testicular ischemia can lead to irreversible necrosis within 4 to 6 hours, the diagnosis is made clinically in clear-cut cases. The definitive management is prompt surgical exploration to detorse the affected testicle and perform bilateral orchiopexy (fixation to the scrotal wall) to prevent future episodes, as the underlying anatomical defect is usually bilateral.

Step-by-Step Solution

1
Analyze the patient's clinical presentation.
Sudden onset of severe scrotal pain, nausea, high-riding horizontal testicle, and absent cremasteric reflex.
To differentiate between etiologies of acute scrotum, such as torsion, epididymitis, or torsion of the appendix testis.
2
Establish the most likely diagnosis.
Testicular torsion.
The constellation of abrupt pain waking the patient from sleep, a horizontal lie, and absent cremasteric reflex is classic for twisting of the spermatic cord.
3
Determine the most appropriate management.
Urgent operative detorsion and bilateral orchiopexy.
Testicular torsion is a surgical emergency; delaying for imaging or medical therapy increases the risk of irreversible testicular infarction.

Key Concept

Patients with a high clinical suspicion for testicular torsion require immediate surgical exploration and bilateral orchiopexy rather than delaying care for diagnostic imaging.
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Topics

Urologic Surgery

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