A 16-year-old boy is brought to the emergency department by his parents due to the sudden onset of severe right scrotal pain that awoke him from sleep 2 hours ago. He has had one episode of vomiting since the pain started. His temperature is 37.1°C (98.8°F), blood pressure is 120/78 mmHg, and pulse is 98/min. Physical examination reveals a swollen, exquisitely tender, and high-riding right testicle with a transverse lie. The right cremasteric reflex is absent. Which of the following is the most appropriate next step in management?
- Immediate surgical explorationAnswer
- BScrotal Doppler ultrasonography
- CIntramuscular ceftriaxone and oral doxycycline
- DScrotal elevation and ice packs
- EUrinalysis and urine culture
Answer
Immediate surgical exploration
The patient's presentation of sudden-onset, severe scrotal pain during sleep, accompanied by nausea or vomiting, an absent cremasteric reflex, and a high-riding testicle, is highly characteristic of testicular torsion. Testicular torsion is a urologic emergency caused by the twisting of the spermatic cord, which compromises the blood supply to the testicle. Because testicular viability decreases significantly after 6 hours of ischemia, a patient with a classic clinical picture should be taken directly to the operating room for immediate surgical exploration and bilateral orchiopexy. Delaying surgery for imaging is contraindicated when the diagnosis is highly likely.
Step-by-Step Solution
Key Concept
Testicular torsion requires emergent surgical exploration without delay for imaging when the clinical presentation is classic (sudden pain, absent cremasteric reflex, high-riding testis).