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Difficulty: MediumUrologic Surgery

A 15-year-old boy is brought to the emergency department by his parents due to severe, sudden-onset right scrotal pain that woke him from sleep 2 hours ago. He reports nausea and has vomited twice. He has no history of trauma, dysuria, or urethral discharge. His temperature is 37.1°C (98.8°F), heart rate is 105/min, and blood pressure is 125/80 mmHg. Physical examination reveals a swollen, exquisitely tender, and high-riding right testicle with a transverse lie. The right cremasteric reflex is absent, while the left is intact. Scrotal elevation does not relieve the pain. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate surgical explorationAnswer
  2. B
    Color Doppler ultrasound of the scrotum
  3. C
    Intramuscular ceftriaxone and oral doxycycline
  4. D
    Computed tomography of the abdomen and pelvis
  5. E
    Urinalysis and urine culture

Answer

The most appropriate next step is immediate surgical exploration.
The correct answer is immediate surgical exploration. This patient presents with the classic triad of testicular torsion: sudden onset of severe scrotal pain, a high-riding transversely oriented testicle, and an absent cremasteric reflex. Testicular torsion is a urologic emergency caused by twisting of the spermatic cord, leading to venous congestion, arterial compromise, and eventual testicular infarction. The window for testicular salvage is extremely narrow, typically 4 to 6 hours from symptom onset. Therefore, when the clinical diagnosis is highly suspected based on history and physical examination, the standard of care is immediate urologic consultation and surgical exploration. Bilateral orchiopexy (fixation of the testicles to the scrotal wall) is performed to prevent recurrence. Ordering any diagnostic imaging, including a Doppler ultrasound, is contraindicated in this scenario as it will delay definitive care and increase the likelihood of orchiectomy.

Step-by-Step Solution

1
Analyze the patient's demographics and history of present illness.
A 15-year-old adolescent boy presents with acute, severe, sudden-onset scrotal pain that woke him from sleep, accompanied by nausea and vomiting.
Sudden onset of severe scrotal pain in an adolescent is highly suspicious for a vascular event like testicular torsion.
2
Evaluate the physical examination findings.
The physical exam shows a high-riding, transversely oriented testicle with an absent cremasteric reflex on the affected side.
An absent cremasteric reflex is the most sensitive physical finding for testicular torsion. A high-riding, transverse lie indicates a 'bell clapper' deformity predisposing to torsion.
3
Determine the optimal management strategy based on clinical suspicion.
The clinical diagnosis of testicular torsion is highly likely, necessitating definitive treatment.
Testicular torsion is a surgical emergency. The testicle can suffer irreversible ischemic damage within 4 to 6 hours of symptom onset. Therefore, when clinical suspicion is high, immediate surgical exploration and bilateral orchiopexy are required without delaying for confirmatory imaging.

Key Concept

Management of high-suspicion acute testicular torsion
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Topics

Urologic Surgery

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