What is the most appropriate management for a child with a painful, irreducible, and non-transilluminating left testicular swelling, suggestive of testicular torsion?

Immediate Surgical Exploration with Orchidopexy

This child requires urgent surgical exploration with detorsion and bilateral orchidopexy—this is testicular torsion until proven otherwise, and delay beyond 6-8 hours risks permanent testicular loss. 1

Clinical Reasoning

The presentation of painful, irreducible, firm scrotal swelling with negative transillumination in a child is pathognomonic for testicular torsion, not an inguinal hernia:

• Testicular torsion is a surgical emergency requiring intervention within 6-8 hours of symptom onset to prevent permanent ischemic damage and testicular loss 1, 2
• The negative transillumination test rules out fluid-filled lesions (hydrocele, communicating hydrocele from hernia) and points toward solid tissue pathology 1
• An irreducible scrotal mass in a child with acute pain is torsion until proven otherwise—hernias in children are typically reducible and less acutely painful 1

Surgical Management Algorithm

The correct answer is B. Orchidopexy, which involves:

• Immediate scrotal exploration to assess testicular viability 1, 3
• Detorsion of the spermatic cord if the testis is salvageable 3, 2
• Bilateral orchidopexy (fixation of both testes) to prevent future torsion, as the contralateral testis has similar anatomical predisposition 1, 3
• Orchiectomy only if the testis is nonviable 2

Why Other Options Are Incorrect

• Herniotomy (A) and Herniorrhaphy (C) are procedures for inguinal hernia repair—completely inappropriate for testicular torsion and would result in testicular loss 1
• Tension-free repair (D) refers to mesh-based hernia repair techniques, which have no role in pediatric testicular pathology 1

Critical Time-Sensitive Considerations

• Testicular salvage rates decline precipitously after 6 hours: surgical outcomes are significantly better when surgery occurs within 12 hours of symptom onset 1
• Do not delay surgery for imaging if clinical suspicion is high—testicular torsion is a clinical diagnosis 1, 2
• The orchiectomy rate in boys undergoing surgery for testicular torsion is 42%, emphasizing the importance of rapid intervention 2

Common Pitfalls to Avoid

• Never mistake testicular torsion for an incarcerated hernia—the negative transillumination and acute severe pain pattern distinguish these entities 1
• Do not wait for Doppler ultrasound if clinical presentation is classic—imaging should not delay surgical exploration 1, 2
• Always perform bilateral orchidopexy, as the bell-clapper deformity (abnormal tunica vaginalis attachment) is typically bilateral, placing the contralateral testis at risk 1, 4

Post-Operative Care

• Bed rest, scrotal elevation, and analgesics until inflammation subsides 1
• Long-term follow-up for testicular atrophy (occurs in 9.1-47.5% of cases) and fertility assessment 3