What is the recommended work-up for suspected testicular torsion in a 14-year-old male?

Work-up for Testicular Torsion in a Fourteen-Year-Old Male

Immediate urological consultation and prompt surgical exploration is required for suspected testicular torsion in a 14-year-old male, as surgical intervention within 6-8 hours of symptom onset is essential to prevent testicular loss. 1, 2

Clinical Assessment

• Testicular torsion occurs more frequently in postpubertal boys, making a 14-year-old male at high risk for this condition 2
• Key clinical features to assess include:
  • Sudden onset of severe unilateral scrotal pain (versus gradual onset in epididymitis) 2, 3
  • Presence of nausea and vomiting (common in testicular torsion) 3, 4
  • Negative Prehn sign (pain not relieved when testicle is elevated) 2, 5
  • Absent cremasteric reflex (present in 94.9% of torsion cases) 6, 7
  • High-riding testicle on the affected side 3

Diagnostic Imaging

• If clinical suspicion is high, do not delay surgical exploration for imaging studies 3
• When time permits without delaying surgical intervention, Duplex Doppler ultrasound is the recommended imaging modality 2, 4:
  • Grayscale examination to assess testicular homogeneity and identify the "whirlpool sign" (96% sensitivity) 2
  • Color Doppler assessment to evaluate testicular perfusion (96-100% sensitivity) 2
  • Key findings include decreased or absent blood flow to the affected testicle 6, 4
  • Heterogeneous echogenicity is associated with non-viable testes 6

Differential Diagnosis Considerations

• The three most common causes of acute scrotal pain in adolescents are 1:
  • Testicular torsion (surgical emergency)
  • Torsion of testicular appendage (most common in prepubertal boys, look for "blue dot sign") 1, 2
  • Epididymitis/epididymo-orchitis (most common in adults, but can occur in adolescents) 1

Management Algorithm

1. If clinical presentation strongly suggests testicular torsion:

   • Immediate urological consultation without waiting for imaging 2, 3
   • Consider manual detorsion while awaiting surgical intervention 7, 4
   • Surgical exploration within 6-8 hours of symptom onset is critical 1, 2

2. If clinical suspicion is intermediate:

   • Urgent Doppler ultrasound of the scrotum 2
   • If ultrasound confirms torsion or is inconclusive but clinical suspicion remains high, proceed to surgical exploration 4

Critical Time Considerations

• The window for testicular salvage is typically 4-8 hours before permanent ischemic damage occurs 3, 7
• Testicular salvage rates correlate directly with time to intervention:
  • Median symptom duration of 12 hours when testes were successfully preserved 6
  • Median symptom duration of 90 hours when testes required removal 6

Common Pitfalls to Avoid

• Delaying surgical consultation to obtain imaging when clinical suspicion is high 3
• Misdiagnosing as epididymitis, which is less common in adolescents than adults 1, 2
• Relying solely on ultrasound findings, as a normal ultrasound cannot completely exclude the diagnosis 4
• Overlooking testicular torsion in patients with partial torsion or intermittent symptoms 7