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Difficulty: EasyUrologic Surgery

An adolescent boy, age 1616, presents to the triage desk reporting severe right-sided scrotal pain that awoke him from sleep approximately 9090 minutes ago. He has no prior medical history and does not report any recent sexual activity or trauma. His temperature is 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), pulse is 105/min105/\text{min}, and blood pressure is 120/75 mm Hg120/75 \text{ mm Hg}. Genitourinary examination demonstrates a diffusely swollen, markedly tender right testicle with a transverse lie, positioned notably higher than the contralateral testis. Stroking the inner aspect of the right thigh produces no testicular elevation, whereas the reflex is intact on the left side. Which of the following is the most appropriate next step in the management of this patient?

  1. Emergent surgical explorationAnswer
  2. B
    Scrotal duplex ultrasonography
  3. C
    Intramuscular ceftriaxone and oral doxycycline
  4. D
    Scrotal elevation and nonsteroidal anti-inflammatory drugs
  5. E
    Urinalysis and urine culture

Answer

Emergent surgical exploration
The correct answer is emergent surgical exploration. This patient's presentation of sudden-onset, severe unilateral scrotal pain that awoke him from sleep, combined with a high-riding, transversely oriented testicle and an absent cremasteric reflex, is highly specific for testicular torsion. Testicular torsion is a surgical emergency caused by the twisting of the spermatic cord, leading to venous congestion and subsequent arterial compromise. Because testicular salvage rates drop significantly after 66 hours of ischemia, definitive treatment with emergent surgical exploration and bilateral orchiopexy is required immediately. In cases where the clinical suspicion is unequivocally high, diagnostic imaging must be bypassed to avoid delaying surgical care.

Step-by-Step Solution

1
Analyze the patient's symptoms and physical examination findings.
The patient has sudden-onset severe scrotal pain, a high-riding testis with a transverse lie, and an absent cremasteric reflex.
These findings must be synthesized to determine the underlying etiology of the acute scrotum.
2
Establish the most likely clinical diagnosis.
The clinical picture is highly specific for testicular torsion.
The absence of the cremasteric reflex is the most sensitive physical exam finding for testicular torsion, distinguishing it from epididymitis or torsion of the appendix testis.
3
Determine the appropriate management for highly suspected testicular torsion.
Immediate urologic consultation and surgical exploration are required.
Testicular viability decreases rapidly after 66 hours of ischemia, making immediate surgery the standard of care without delaying for imaging.

Key Concept

Patients with a high clinical suspicion for testicular torsion (characterized by sudden-onset pain, high-riding testicle, and absent cremasteric reflex) should undergo emergent surgical exploration without delay for ultrasound imaging.
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Urologic Surgery

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