What is the most appropriate initial step in managing a patient with suspected testicular torsion, presenting with severe pain, decreased blood flow, and a history of Bell clapper deformity?

Management of Suspected Testicular Torsion

The most appropriate initial step is immediate surgical exploration (emergent scrotal exploration with detorsion and bilateral orchiopexy), as this patient presents with classic testicular torsion confirmed by decreased blood flow on Doppler ultrasonography and a known anatomic predisposition (Bell clapper deformity). 1

Rationale for Emergent Surgical Intervention

Surgical exploration and detorsion must be performed within 6-8 hours of symptom onset to prevent permanent ischemic damage and testicular loss. 2, 1 This patient has already had symptoms for one hour with confirmed decreased blood flow on imaging, making this a true surgical emergency. 1

The combination of clinical findings strongly supports testicular torsion:

• Severe pain awakening from sleep with acute onset 1
• Pain radiating to the testicle 1
• Associated nausea (present in 25% of cases) 3
• Known Bell clapper deformity (anatomic predisposition) 4, 3
• Swollen, discolored, tender hemiscrotum 1
• Decreased blood flow on Doppler ultrasonography (sensitivity 96-100%) 1, 5

Why Other Options Are Inappropriate

Admission for observation is contraindicated because testicular viability decreases dramatically after 6-8 hours, and any delay in surgical intervention increases the risk of testicular loss and compromises salvage rates. 2, 1

Application of heat to the scrotum has no role in testicular torsion management and would only delay definitive treatment. 1

Manual detorsion alone is insufficient as definitive management. While manual detorsion can be attempted as a temporizing measure to maximize testis salvage before surgical exploration, it has only a 26% success rate, and even when successful, all patients still require surgical bilateral orchiopexy to prevent recurrence. 6 In this case with confirmed imaging, proceeding directly to surgery is most appropriate. 1

Suspensory scrotal support devices are used for supportive care in conditions like epididymitis, not for testicular torsion, which requires immediate surgical correction. 1

Emergent orchiectomy (testicular removal) is not the initial surgical step. The correct procedure is emergent scrotal exploration with attempted detorsion and assessment of testicular viability, followed by bilateral orchiopexy if the testis is salvageable. 1 Orchiectomy is only performed if the testis is nonviable after detorsion attempts. 1

Critical Clinical Considerations

The Bell clapper deformity present in this patient represents a bilateral anatomic abnormality where the tunica vaginalis has abnormally high insertion, allowing the testis to rotate freely within the scrotum. 4, 3 This finding was present in 82% of patients with intermittent testicular torsion in one series and mandates bilateral orchiopexy during surgery to prevent contralateral torsion. 3

Bilateral orchiopexy must be performed because the anatomic defect is bilateral in the majority of cases, and the risk of contralateral torsion is significant. 1, 4, 3

The history of previous appendicitis is irrelevant to this acute presentation and should not influence management decisions. 1

Surgical Approach

The definitive surgical procedure involves:

• Inguinal or scrotal exploration with detorsion of the affected testis 1
• Assessment of testicular viability after detorsion 1
• Bilateral orchiopexy with fixation to the scrotal wall using non-absorbable sutures (typically 3 separate sutures) to prevent recurrence 4, 3
• Orchiectomy only if the testis is nonviable after detorsion 1

Time is testicular tissue—every minute of delay increases the risk of permanent damage and gonadal loss. 2, 1