What are the symptoms and treatment options for a protrusion and cord issue in the testicle, possibly indicating testicular torsion or hernia?

Testicular Protrusion and Cord Issues: Diagnosis and Management

Immediate Action Required

If you are evaluating a patient with acute scrotal pain and a palpable cord abnormality, this is testicular torsion until proven otherwise—immediate urological consultation and surgical exploration are mandatory, as testicular viability is compromised if not treated within 6-8 hours of symptom onset. 1

Clinical Presentation and Key Distinguishing Features

Testicular Torsion (Surgical Emergency)

• Abrupt onset of severe, unilateral scrotal pain with nausea and vomiting 1, 2
• Absent cremasteric reflex is the most accurate clinical sign (ipsilateral) 3, 4
• High-riding testicle with abnormal lie on examination 2
• Negative Prehn sign: pain is NOT relieved when elevating the testicle 1
• Occurs most commonly in adolescents (bimodal distribution: neonates and postpubertal boys aged 12-18 years) 1, 4
• Normal urinalysis does NOT exclude torsion 1

Inguinal Hernia with Cord Involvement

• More gradual onset compared to torsion 1
• Palpable mass extending into inguinal canal 5
• May have reducible bulge (though incarcerated hernias are surgical emergencies) 5
• Critical pitfall: Testicular torsion and incarcerated inguinal hernia can occur simultaneously—maintain broad differential 5

Diagnostic Algorithm

Step 1: Clinical Risk Stratification

• High clinical suspicion (severe acute pain, absent cremasteric reflex, high-riding testis): Proceed DIRECTLY to surgical exploration—do NOT delay for imaging 1, 2
• Intermediate suspicion: Urgent Duplex Doppler ultrasound of scrotum 1

Step 2: Imaging When Appropriate

Duplex Doppler ultrasound is the first-line imaging modality 6, 1:

• Grayscale findings in torsion: Enlarged heterogeneous testis (may be hypoechoic), ipsilateral hydrocele, scrotal skin thickening 6, 1
• "Whirlpool sign": Spiral twist of spermatic cord—this is the MOST SPECIFIC ultrasound finding for torsion (96% sensitivity) 6, 1, 7
• Color/Power Doppler: Decreased or absent testicular blood flow 6, 1
• Spectral Doppler: Absent or reversed diastolic flow, diminished arterial velocity, increased resistive index 6
• Use contralateral asymptomatic testicle as internal control 6, 1

Critical imaging pitfalls:

• Ultrasound sensitivity ranges 69-96.8%, specificity 87-100%—a normal ultrasound does NOT exclude torsion 6, 4
• False negatives occur with partial torsion or spontaneous detorsion 6, 1
• Early torsion (first few hours) may appear normal on imaging 6
• False positives in infants/young boys with normally reduced testicular blood flow 6

Treatment Protocol

Immediate Management

1. Emergent urological consultation upon clinical suspicion—do not wait for imaging confirmation if high suspicion 1, 2
2. Surgical exploration and detorsion within 6-8 hours of symptom onset to prevent permanent ischemic damage 1, 7, 2
3. Manual detorsion can be attempted in emergency department while awaiting surgery (external rotation), but blood flow restoration must be confirmed 3, 4

Surgical Outcomes

• Testicular salvage rate depends on degree of torsion (180-720+ degrees) and duration of ischemia 6, 7
• Optimal intervention window: <6 hours; outcomes worsen significantly after 12 hours 1, 2
• Orchiectomy rate is 42% in boys undergoing surgery for testicular torsion when diagnosis is delayed 2
• Bilateral orchiopexy (affected and contralateral testis) is performed to prevent future torsion 3

Post-Operative Care

• Bed rest, scrotal elevation, and analgesics until inflammation subsides 1

Common Pitfalls to Avoid

• Never delay surgical consultation for imaging if clinical presentation strongly suggests torsion 1, 2
• Do not rely on cremasteric reflex alone—while absent reflex is highly suggestive, its presence does not exclude torsion 4
• Do not assume normal urinalysis excludes torsion—this is an infection-independent vascular emergency 1
• Consider concurrent pathology: Rare cases of simultaneous torsion and incarcerated hernia have been reported 5
• Partial torsion presents diagnostic challenges: May have preserved arterial flow with only venous obstruction, requiring spectral Doppler analysis at upper, mid, and lower testicular poles 6