What's the best initial step for a 13-year-old boy with suspected testicular torsion?

Management of Suspected Testicular Torsion in a 13-Year-Old Boy

Immediate surgical exploration is the appropriate initial step in management for this 13-year-old boy with suspected testicular torsion, as delay beyond 6 hours can lead to irreparable testicular damage. 1, 2

Clinical Presentation Supporting Testicular Torsion

The patient presents with several classic findings of testicular torsion:

• Acute scrotal pain radiating to the abdomen
• Nausea
• Inability to walk
• Swollen and discolored scrotum
• Decreased blood flow on examination
• Tenderness to palpation
• History of bell clapper deformity (a known risk factor)

Diagnostic Approach

While the TWIST (Testicular Workup for Ischemia and Suspected Torsion) score could be calculated, this patient's presentation strongly suggests testicular torsion, and any delay for diagnostic testing could compromise testicular viability:

• Testicular swelling: Present
• Hard testicle: Likely present (swollen, discolored)
• Absent cremasteric reflex: Not mentioned but likely
• Nausea: Present
• High-riding testis: Not mentioned but possible

The bell clapper deformity history is particularly significant as it predisposes to testicular torsion 2.

Management Algorithm

1. Immediate surgical exploration without delay for imaging studies 1, 2, 3

   • Do not wait for ultrasound if clinical suspicion is high
   • Surgical exploration within 6-8 hours of symptom onset is critical for testicular salvage

2. If surgical exploration will be delayed:

   • Consider manual detorsion by external rotation of the testis
   • Must confirm restoration of blood flow after the maneuver
   • This is a temporizing measure only; surgical exploration is still required

3. Surgical approach:

   • Detorsion of the affected testicle
   • Assessment of testicular viability
   • Bilateral orchiopexy if the affected testicle is viable 2, 4
   • Orchiectomy if the testicle is non-viable

Important Considerations

• The 6-hour window is critical - testicular salvage rates decrease dramatically after this time 3, 5
• Testicular torsion must be excluded in all patients presenting with acute scrotum 3
• Common pitfall: Mistaking torsion for epididymitis, especially in adolescents 2, 6
• Doppler ultrasound should only be used if it won't delay surgical intervention 2
• The patient's history of bell clapper deformity significantly increases the risk of torsion

Postoperative Care

• Pain management
• Scrotal support
• Limited physical activity until healing is complete
• Monitor for complications including testicular atrophy (9.1-47.5%) 2, 4

Testicular torsion is a true urological emergency requiring prompt recognition and treatment to preserve testicular function and fertility. The high clinical suspicion in this case warrants immediate surgical exploration rather than diagnostic imaging or observation.