What is the appropriate initial step for a 13-year-old male with severe lower abdominal pain radiating to his right testicle, decreased blood flow on ultrasound, and a swollen scrotum, indicating potential testicular torsion?

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

Immediate surgical exploration is the appropriate initial step for this patient with suspected testicular torsion presenting with decreased testicular blood flow on ultrasound, scrotal swelling, and discoloration. 1, 2

Clinical Assessment and Diagnosis

The patient's presentation strongly suggests testicular torsion:

• 13-year-old male with acute severe lower abdominal pain radiating to right testicle
• Ultrasound showing decreased blood flow to the right testicle
• Physical examination revealing swelling, discoloration, and tenderness of the scrotum

These findings are classic for testicular torsion, which is a surgical emergency requiring immediate intervention. The decreased blood flow on ultrasound is particularly concerning, as it is the most sensitive finding for torsion 1.

Why Immediate Surgical Exploration is Necessary

• Time-critical condition: There is typically only a 4-8 hour window before permanent ischemic damage occurs to the testicle 2
• High diagnostic certainty: The combination of acute pain and decreased blood flow on ultrasound has a sensitivity of 91.7% and specificity of 99.2% for testicular torsion 1
• Risk of testicular loss: Delay in treatment may necessitate orchiectomy or lead to decreased fertility 2

Surgical Management

The surgical approach involves:

1. Immediate scrotal exploration
2. Manual detorsion of the affected testicle
3. Assessment of testicular viability
4. Bilateral orchiopexy (fixation of both testes) to prevent recurrence 3

If the testicle is not viable (black or blue with no bleeding after detorsion), orchiectomy may be necessary.

Important Considerations

• Do not delay for additional imaging: When clinical and ultrasound findings suggest torsion, immediate surgical exploration is indicated and should not be postponed for additional imaging studies 2
• Bilateral orchiopexy: Even though only one testicle is affected, bilateral fixation is standard practice to prevent future torsion of either testicle 3
• Previous appendectomy is not relevant: The patient's history of appendectomy three years ago does not affect the management of suspected testicular torsion

Differential Diagnosis

While the presentation strongly suggests testicular torsion, other conditions to consider include:

• Epididymo-orchitis: Usually has more gradual onset of pain and increased (not decreased) blood flow on ultrasound 4
• Torsion of testicular appendage: Often presents with the "blue dot sign" and normal testicular blood flow 1
• Segmental testicular infarction: Typically presents as a wedge-shaped avascular area rather than global decreased flow 1

The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score can help assess risk, with high scores (≥5) indicating need for immediate surgical exploration rather than additional imaging 1, 4.

Prognosis

Testicular salvage rates are directly related to the time from onset of symptoms to detorsion:

• Within 6 hours: >90% salvage rate
• 6-12 hours: 50-70% salvage rate

• 12 hours: <10% salvage rate 2, 5

Given this patient's presentation with only 1 hour of symptoms, prompt surgical intervention offers the best chance for testicular preservation and future fertility.