What is the differential diagnosis and workup for a patient with acute onset of lower abdominal and testicular pain after feeling a pop in the groin region while chopping wood, with a history of inguinal hernia (hernia in the groin area) repair at a young age and physical exam findings of absent testicles in the scrotum with both testicles palpable in the suprapubic region?

Bilateral Testicular Ascent Following Acute Groin Trauma

Immediate Diagnosis

This patient has bilateral testicular torsion with complete ascent of both testes into the suprapubic region, representing a urological emergency requiring immediate surgical exploration without delay for imaging. 1

Clinical Reasoning

The presentation is pathognomonic for bilateral testicular torsion:

• Acute traumatic onset with audible "pop" during physical exertion (chopping wood) indicates sudden spermatic cord twisting 1
• Complete testicular ascent into the suprapubic region with empty scrotum is a classic finding of severe torsion with complete cord rotation 1
• History of infant inguinal hernia repair may have altered normal testicular fixation, predisposing to the "bell-clapper" deformity found in 82% of patients with torsion 1
• Persistent pain in both lower abdomen and "testicular" region (now suprapubic) indicates ongoing ischemia 1

Critical Time Window

Surgical detorsion must occur within 6-8 hours of symptom onset to prevent permanent testicular loss. 1, 2 Every minute of delay increases the risk of bilateral testicular necrosis and subsequent infertility. 1

Immediate Management Algorithm

Step 1: Emergent Urological Consultation (Within Minutes)

• Do not obtain imaging - the physical examination findings of bilateral testicular ascent with empty scrotum are diagnostic 1
• High clinical suspicion mandates immediate surgical exploration regardless of ultrasound availability 1
• The American College of Radiology explicitly states that imaging should never delay surgical exploration when clinical suspicion is high 1

Step 2: Immediate Surgical Exploration

• Bilateral inguinal or scrotal exploration with manual detorsion of both spermatic cords 1
• Assessment of testicular viability after detorsion (color, capillary refill, arterial pulsation) 1
• Bilateral orchiopexy is mandatory even if one or both testes are nonviable, as the bell-clapper deformity affects both sides 1
• Orchiectomy only if testis is clearly necrotic and nonviable 2

Differential Diagnosis (Less Likely but Consider)

While bilateral testicular torsion is the diagnosis, briefly consider:

• Bilateral inguinal hernia incarceration: However, this would not cause complete testicular ascent into suprapubic region; testes would remain palpable in inguinal canal 1
• Severe bilateral epididymitis: Would show gradual onset, not acute "pop," and testes would remain in scrotum with increased blood flow on Doppler 1
• Traumatic testicular dislocation: Rare but possible with severe trauma; however, patient's mechanism (chopping wood) is insufficient force for true dislocation 3

Key Clinical Pitfalls to Avoid

• Never delay surgery for imaging when physical examination shows absent testes in scrotum with suprapubic palpable masses and acute pain onset 1
• Do not be falsely reassured by any preserved Doppler flow if obtained - partial torsion can show diminished but present arterial flow while venous obstruction causes progressive ischemia 1
• Recognize that bilateral simultaneous torsion is rare but catastrophic - the history of infant hernia repair may have created bilateral anatomic predisposition 1
• Absence of cremasteric reflex is highly predictive of torsion (sensitivity approaching 100%), though this cannot be assessed with ascended testes 4

Prognostic Factors

• Testicular salvage rate approaches 90-100% if detorsion occurs within 6 hours 1
• Salvage rate drops to 20-50% between 12-24 hours 1
• Bilateral testicular loss would result in permanent infertility and lifelong testosterone replacement requirement 1

Post-Operative Management

Following successful bilateral detorsion and orchiopexy:

• Bed rest with scrotal elevation 1
• Analgesics for pain control 1
• Monitor for testicular atrophy over subsequent months 1
• Endocrine follow-up if bilateral orchiectomy required 1