What is the most appropriate initial management for a 14-year-old boy with acute scrotum, severe testicular pain, and vomiting after a genital trauma, presenting with fever, tachycardia, and a swollen, tender left testicle?

Immediate Surgical Consultation for Suspected Testicular Torsion

This 14-year-old requires immediate urological consultation for emergency scrotal exploration—testicular torsion must be ruled out surgically given the clinical presentation of acute severe testicular pain, firm tender testicle, and systemic symptoms, as testicular salvage depends on intervention within 6-8 hours. 1

Clinical Reasoning

Why This is Testicular Torsion Until Proven Otherwise

• The clinical presentation is classic for testicular torsion: sudden onset of severe unilateral testicular pain (4 hours duration), vomiting (occurred twice), firm and exquisitely tender testicle, and scrotal swelling with discoloration 1
• The trauma history is a red herring: while the patient was kicked in the genitals, the progressive worsening pain over 4 hours with systemic symptoms (fever 101.3°F, tachycardia at 104 bpm) and the firm, tender testicle suggest torsion rather than simple traumatic injury 2
• Time is testicle: testicular torsion has a bimodal distribution with peaks in neonates and adolescents, and requires surgical detorsion within 6-8 hours to prevent permanent testicular loss 1

The Correct Answer: Surgical Consultation

Immediate urological consultation for scrotal exploration is the only appropriate initial management. 1 The American College of Radiology guidelines emphasize that when clinical suspicion for torsion is high, proceeding directly to emergency surgical exploration without waiting for imaging is recommended 3.

• Testicular torsion is a surgical emergency requiring manual detorsion or operative detorsion with orchiopexy 1
• Even if ultrasound were performed and showed decreased flow, the treatment would still be immediate surgery 1
• Delaying for imaging when clinical suspicion is high risks testicular loss 3

Why the Other Options Are Wrong

IV Lactated Ringer's Solution

• While IV fluids may be appropriate for supportive care in a febrile, vomiting patient, this does not address the surgical emergency 4, 5
• Lactated Ringer's is superior to normal saline for resuscitation in various conditions, but fluid resuscitation alone will not save the testicle 5, 6
• This would represent a dangerous delay in definitive management

IV Administration of Penicillin

• Antibiotics would be appropriate for epididymitis/epididymo-orchitis, but the clinical picture does not fit: epididymitis typically has gradual onset, positive Prehn sign (pain relief with elevation), and increased blood flow on ultrasound 1
• The acute onset, severe pain, and firm testicle point to torsion, not infection 1
• Starting antibiotics would delay the correct diagnosis and treatment

Oral Prednisone

• Corticosteroids have no role in acute testicular torsion management 1
• This would represent a catastrophic delay in surgical intervention

Neurology Consultation

• There is no neurological indication in this presentation 1
• This is a urological surgical emergency

Hyperbaric Oxygen Therapy

• Hyperbaric oxygen has no established role in testicular torsion management 1
• This would represent an inappropriate and dangerous delay

Critical Management Algorithm

1. Recognize the emergency: Acute severe testicular pain + firm tender testicle + systemic symptoms = torsion until proven otherwise 1
2. Call urology immediately: Do not wait for imaging if clinical suspicion is high 3
3. Prepare for OR: The patient needs scrotal exploration, manual detorsion, assessment of testicular viability, and bilateral orchiopexy 1
4. Supportive care while mobilizing: IV access, NPO status, analgesia as needed—but do not delay surgery 1

Common Pitfalls to Avoid

• Do not be misled by the trauma history: Trauma can precipitate torsion or the trauma may be coincidental 2, 1
• Do not wait for ultrasound: When clinical suspicion is high, imaging delays definitive treatment 3
• Do not assume it's epididymitis because of fever: Torsion can cause fever and leukocytosis due to testicular ischemia 1
• Do not assume the reddish-purple scrotum rules out torsion: This can occur with torsion due to venous congestion and ischemia 1