Immediate Surgical Exploration
Proceed directly to immediate surgical exploration without delay for imaging studies. 1, 2
Clinical Reasoning
The combination of acute scrotal pain with an absent cremasteric reflex is highly predictive of testicular torsion and constitutes a surgical emergency requiring immediate intervention. 2, 3
Why Imaging Should NOT Delay Surgery
Do not postpone surgical exploration to perform ultrasound when clinical findings strongly suggest testicular torsion, as the absent cremasteric reflex is the most accurate clinical sign of this diagnosis. 2, 4
The critical time window is 6-8 hours from symptom onset before permanent ischemic damage occurs, with testicular salvage rates declining significantly after this period. 1, 2
Studies demonstrate that the interval between pain onset and treatment directly impacts outcomes: mean time of 11.4 hours when the testis was salvaged versus 19.0 hours when orchiectomy was required (p<0.001). 3
Clinical Scoring and Decision Algorithm
The combination of clinical findings creates a high-probability scenario for testicular torsion: 5
- Duration of pain ≤6 hours: 1 point
- Absent or decreased cremasteric reflex: 1 point
- Diffuse testicular tenderness: 1 point
With a score of 3/3,87% of patients have testicular torsion, warranting immediate surgical exploration without imaging. 5
Role of Ultrasound (If Any)
Ultrasound should only be considered in lower probability cases (score 1-2), not in high-probability presentations like this one. 5
Common pitfall: False-negative Doppler studies occur in 4-31% of cases due to partial torsion or spontaneous detorsion, and normal testicular flow does NOT exclude torsion. 6, 5