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Difficulty: MediumPhysical Examination Findings

A 19-year-old man presents to the emergency department with severe, sudden-onset right scrotal pain that awoke him from sleep two hours ago. He reports no recent trauma, fever, dysuria, or urethral discharge. Vital signs are within normal limits except for a heart rate of 105/min. On physical examination, the right testicle is diffusely swollen, exquisitely tender, and has a transverse lie. It is positioned significantly higher in the scrotum compared to the left testicle. When the examiner manually elevates the right hemiscrotum, the patient reports no relief in his pain. Based on the most likely diagnosis, which of the following additional physical examination findings is most likely to be present in this patient?

  1. Loss of elevation of the right testicle upon stroking the ipsilateral inner thighAnswer
  2. B
    A small, firm, palpable nodule with a bluish discoloration at the superior pole of the testis
  3. C
    Exquisite tenderness strictly localized to the posterior aspect of the testicle
  4. D
    A painless, fluid-filled cystic mass surrounding the testicle that brightly transilluminates
  5. E
    A soft, irregular, palpable mass in the spermatic cord that enlarges during the Valsalva maneuver

Answer

Loss of elevation of the right testicle upon stroking the ipsilateral inner thigh
The clinical presentation of sudden-onset, severe scrotal pain during sleep, combined with a high-riding, transversely oriented testicle and a negative Prehn sign (lack of pain relief with manual scrotal elevation), is highly characteristic of testicular torsion. Testicular torsion is a urologic emergency caused by the twisting of the spermatic cord, which compromises testicular blood supply and can lead to irreversible ischemia if not surgically untwisted promptly. The most sensitive and specific physical examination finding for testicular torsion is the absence of the ipsilateral cremasteric reflex. This reflex is elicited by lightly stroking the superior, inner aspect of the thigh and observing for the contraction of the cremaster muscle, which elevates the testicle. In testicular torsion, the reflex is lost because the twisted spermatic cord mechanically prevents elevation and the ongoing ischemia disrupts the reflex arc.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and vital signs.
The patient is a young male with sudden-onset, severe scrotal pain during sleep, with mild tachycardia but no fever or infectious symptoms.
To differentiate acute, life-threatening or organ-threatening etiologies from infectious or chronic conditions.
2
Evaluate the specific physical examination findings provided in the stem.
The right testicle is high-riding, has a transverse lie, and exhibits a negative Prehn sign (no pain relief with elevation).
These findings heavily correlate with mechanical compromise of the spermatic cord rather than an inflammatory process like epididymitis.
3
Synthesize findings to establish the most likely diagnosis and identify the key confirmatory physical sign.
The clinical picture is pathognomonic for testicular torsion. The most specific additional physical exam finding for this condition is an absent cremasteric reflex.
Torsion twists the spermatic cord, mechanically tethering the testicle and causing ischemia that disrupts the cremasteric reflex arc.

Key Concept

Testicular torsion presents with acute, severe scrotal pain, a high-riding and transversely oriented testicle, a negative Prehn sign, and an absent cremasteric reflex.
Estimated Time:1m 0s
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Physical Examination Findings

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