During a high school basketball tournament, a 16-year-old boy suddenly drops to the floor,… — USMLE Step 2 CK

During a high school basketball tournament, a 16-year-old boy suddenly drops to the floor, gripping his groin. He is rushed to the nearest acute care center. Upon evaluation, he reports an abrupt onset of agonizing right-sided testicular pain accompanied by nausea and one episode of emesis. He denies any direct trauma to the groin during the game. His temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $130/80\text{ mm Hg}$ , and pulse is $115/\text{min}$ . Physical examination reveals a markedly swollen, tender, and erythematous right hemiscrotum. The right testis is significantly elevated compared to the left and rests in a transverse orientation. Stroking the superior medial aspect of the right thigh yields no elevation of the right testis, although the reflex is completely intact on the left side. Which of the following is the most appropriate next step in the management of this patient?

Immediate bilateral scrotal explorationAnswer
B
Scrotal duplex ultrasonography
C
Administration of intramuscular ceftriaxone and oral doxycycline
D
Manual testicular detorsion and discharge with outpatient follow-up
E
Urinalysis and midstream urine culture

Answer

Immediate bilateral scrotal exploration

The correct approach is immediate bilateral scrotal exploration. Testicular torsion occurs due to inadequate fixation of the lower pole of the testis to the tunica vaginalis (the 'bell clapper' deformity), allowing the spermatic cord to twist and occlude blood flow. The clinical diagnosis is established by the acute onset of severe pain, nausea, vomiting, a high-riding transversely oriented testis, and notably, the absence of the cremasteric reflex. Because testicular salvage rates drop precipitously after

4

6\text{ hours}

of ischemia, patients with a classic presentation must be taken immediately to the operating room for surgical detorsion and bilateral orchiopexy (fixation of both testes to prevent future torsion). Imaging is not indicated when clinical suspicion is very high.

Step-by-Step Solution

Analyze the clinical presentation and physical examination findings.

The patient has abrupt, severe scrotal pain, nausea, an elevated and transversely oriented testis, and an absent cremasteric reflex.

Identifying these key features differentiates testicular torsion from other causes of the acute scrotum, such as epididymitis or torsion of the appendix testis.

Determine the necessity of diagnostic imaging versus immediate intervention.

The clinical diagnosis of testicular torsion is highly likely based on the classic presentation, meaning intervention should not be delayed.

The viability of the testis decreases significantly after

6\text{ hours}

of ischemia. Scrotal ultrasound is reserved for equivocal cases where the diagnosis is uncertain.

Select the definitive management step.

Immediate surgical exploration is indicated.

Surgery allows for definitive detorsion, assessment of testicular viability, and bilateral orchiopexy to prevent future episodes.

Key Concept

Patients presenting with classic signs of acute testicular torsion (sudden pain, high-riding transverse testis, absent cremasteric reflex) require immediate surgical exploration and bilateral orchiopexy. Imaging should not be performed as it delays definitive ischemic rescue.

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