What is the recommended management for testicular torsion with tenderness and loss of reflex but no swelling?

Management of Testicular Torsion with Tenderness and Loss of Reflex but No Swelling

Immediate surgical exploration is required for suspected testicular torsion even in the absence of swelling, as the presence of tenderness and absent cremasteric reflex are highly suggestive of torsion and require urgent intervention to prevent testicular loss. 1, 2

Clinical Presentation and Diagnosis

Testicular torsion presents with several key features that help distinguish it from other causes of scrotal pain:

• Classic signs of testicular torsion:
  • Sudden onset of severe unilateral scrotal pain
  • Absent cremasteric reflex (highly significant finding)
  • High-riding testicle
  • Tenderness on palpation
  • Nausea/vomiting (common associated symptom)

It's important to note that while swelling is common in testicular torsion, its absence does not rule out the diagnosis 3. The combination of tenderness and absent cremasteric reflex is highly concerning for torsion even without swelling.

Diagnostic Approach

1. Clinical assessment is paramount:

   • The absence of cremasteric reflex is a critical finding that strongly suggests testicular torsion 1, 2
   • Negative Prehn's sign (pain not relieved by elevation) supports torsion diagnosis 1

2. Imaging studies:

   • Scrotal ultrasound with Doppler should be performed urgently to evaluate blood flow 1, 2
   • Decreased or absent blood flow on Doppler ultrasound confirms the diagnosis
   • However, a normal ultrasound cannot completely exclude torsion 2

Management Algorithm

1. Immediate urological consultation:

   • Do not delay urological consultation if torsion is suspected 2
   • Outcomes are time-sensitive with testicular salvage rates declining rapidly after 6 hours

2. While awaiting surgical intervention:

   • Manual detorsion can be attempted in the emergency department 2, 4
   • Technique: External rotation of the testicle (typically "open book" direction - lateral to medial)
   • Pain relief suggests successful detorsion but does not eliminate need for surgery

3. Definitive treatment:

   • Surgical exploration is mandatory even if symptoms improve 2, 5
   • Surgical detorsion if torsion is confirmed
   • Bilateral orchiopexy (fixation of both testes) to prevent recurrence
   • Orchiectomy if the testicle is non-viable

Important Considerations

• Time is critical: Testicular salvage rates approach 90% if surgery occurs within 6 hours of symptom onset, but drop to less than 10% after 24 hours 2

• Atypical presentations: Testicular torsion can present without all classic symptoms, and the absence of swelling should not delay intervention when other signs (tenderness, absent reflex) are present 3

• Differential diagnosis: The main differential is epididymitis, which typically has:

  • Gradual onset (vs. sudden in torsion)
  • Present cremasteric reflex (vs. absent in torsion)
  • Normal testicular position (vs. high-riding in torsion)
  • Increased blood flow on Doppler (vs. decreased in torsion) 1

Common Pitfalls to Avoid

• Delaying surgical consultation while waiting for imaging when clinical suspicion is high
• Assuming torsion is not present due to absence of swelling when other signs are present
• Relying solely on ultrasound to rule out torsion, as false negatives can occur
• Failing to consider torsion in patients with less severe pain, as some cases may present with minimal pain 3

Remember that testicular torsion is a surgical emergency, and the priority is to restore blood flow to the affected testicle as quickly as possible to prevent ischemia and preserve testicular function.