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Difficulty: HardUrologic Surgery

An 1818-year-old man is brought to the emergency department due to severe, sudden-onset left scrotal pain that woke him from sleep 44 hours ago. The pain is continuous and radiates to his left lower abdomen. He reports one episode of vomiting and significant nausea. One month ago, he had a similar episode of left-sided scrotal pain that resolved spontaneously after 3030 minutes. He has no significant past medical history and is not sexually active. His temperature is 37.2∘37.2^\circ C (99.0∘99.0^\circ F), blood pressure is 135/85135/85 mm Hg, and pulse is 108108/min. On physical examination, the left hemiscrotum is swollen, erythematous, and exquisitely tender to palpation. The left testis is positioned higher in the scrotum compared to the right and has a transverse orientation. The cremasteric reflex is absent on the left side but intact on the right. Elevation of the left testis exacerbates the pain. Urinalysis reveals 88 WBCs/hpf, 00 RBCs/hpf, and negative leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

  1. A
    Color Doppler ultrasonography of the scrotum
  2. B
    Intramuscular ceftriaxone and oral doxycycline
  3. Immediate bilateral scrotal explorationAnswer
  4. D
    Nucleic acid amplification testing of the urine
  5. E
    Scrotal elevation and nonsteroidal anti-inflammatory drugs

Answer

Immediate bilateral scrotal exploration
The correct response is immediate bilateral scrotal exploration. This patient presents with classic signs of acute testicular torsion: severe, sudden-onset pain that wakes the patient from sleep, nausea and vomiting, a high-riding and transversely oriented testis, and an absent cremasteric reflex. The history of a prior, self-resolving episode is highly suggestive of intermittent torsion due to a congenital 'bell-clapper' deformity (lack of normal fixation of the testis to the tunica vaginalis). When the clinical presentation is unequivocal, as in this case, any delay in management risks irreversible ischemic damage to the testicle (viability decreases rapidly after 4−64-6 hours). Therefore, the standard of care is immediate surgical exploration with detorsion and bilateral orchiopexy (fixation of both testes, as the deformity is typically bilateral). The presence of mild pyuria (88 WBCs/hpf) is a known distractor; a reactive sterile pyuria can occur due to local inflammation from ischemia and does not preclude the diagnosis of torsion.

Step-by-Step Solution

1
Analyze the clinical presentation.
The patient has sudden-onset severe scrotal pain, nausea, vomiting, a high-riding transversely oriented testis, and an absent cremasteric reflex.
These findings are highly specific for acute testicular torsion.
2
Evaluate the patient's prior history.
The patient had a previous similar self-resolving episode.
This indicates intermittent testicular torsion, which is a hallmark of the underlying anatomical bell-clapper deformity.
3
Interpret the urinalysis results in the clinical context.
The urinalysis shows mild pyuria (88 WBCs/hpf) without nitrites or leukocyte esterase.
Sterile pyuria can occur in testicular torsion as an inflammatory response to ischemia and does not rule out the diagnosis or confirm an infection.
4
Determine the optimal management strategy based on the diagnosis.
Immediate bilateral scrotal exploration is selected.
When clinical suspicion for testicular torsion is high, imaging should be bypassed to avoid delaying definitive surgical salvage (detorsion and bilateral orchiopexy).

Key Concept

Patients with high clinical suspicion for testicular torsion (e.g., absent cremasteric reflex, severe sudden pain) require immediate surgical exploration; diagnostic imaging should be reserved only for equivocal cases.
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Topics

Urologic Surgery

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