What is the likely diagnosis for a patient with a tender nodule on the superior left testicle, bilateral testicular tenderness, and absence of cremasteric reflex, who has a history of enlarged bladder and is currently taking supplements, including magnesium, glucosamine, folic acid, vitamin D, and vitamin C, and presents with dull, achy left testicular pain worsened by prolonged sitting or tight clothing?

Urgent Evaluation for Testicular Torsion Required

This patient requires immediate scrotal Doppler ultrasound and urgent urology consultation to rule out testicular torsion, despite the intermittent nature of symptoms. The absence of cremasteric reflex combined with a palpable tender nodule and bilateral testicular tenderness creates high clinical suspicion for torsion, which is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss 1.

Critical Clinical Features Suggesting Torsion

The absent cremasteric reflex is present in 94.9% of testicular torsion cases and strongly suggests this diagnosis 2, 3. While this sign is highly sensitive, it is not 100% specific—torsion can occur with an intact reflex 4. Key concerning features in this patient include:

• Tender nodule on superior left testicle - may represent the twisted spermatic cord or ischemic testicular tissue 1
• Bilateral testicular tenderness - the contralateral testis may be tender from reactive changes or underlying bell-clapper deformity 1
• Absent cremasteric reflex - found in 95% of torsion cases 2
• Intermittent, positional pain - classic for intermittent torsion with spontaneous detorsion episodes 5

Immediate Diagnostic Algorithm

Step 1: Urgent Doppler Ultrasound (Do Not Delay if High Suspicion)

Order duplex Doppler ultrasound of the scrotum immediately, which has 69-96.8% sensitivity and 87-100% specificity for testicular torsion 1. The examination must include:

• Grayscale assessment - look for enlarged heterogeneous hypoechoic testis, the "whirlpool sign" of twisted spermatic cord (96% sensitivity), ipsilateral hydrocele, and scrotal wall thickening 1
• Color/Power Doppler - assess for decreased or absent testicular blood flow compared to contralateral side (sensitivity 96-100%) 1
• Spectral Doppler analysis - evaluate for diminished arterial velocity, decreased/absent diastolic flow, or reversed diastolic flow 1
• Power Doppler is preferred for detecting low-flow states, particularly important if partial torsion is present 1

Step 2: Interpret Results with Clinical Context

Critical pitfall: False-negative Doppler occurs in 30% or more of cases, particularly with partial torsion (<450 degrees), spontaneous detorsion, or early presentation 1. If clinical suspicion remains high despite normal Doppler, proceed directly to surgical exploration 1, 5.

Complete torsion (>450 degrees) shows absent arterial and venous flow, but partial torsion may show persistent arterial flow because venous obstruction occurs first 1. This creates the most challenging diagnostic scenario.

Differential Diagnosis by Likelihood

Primary Concern: Intermittent Testicular Torsion (Most Urgent)

• Intermittent torsion with spontaneous detorsion explains the positional, intermittent pain pattern 5
• The testis may detorse spontaneously, creating waxing/waning symptoms 5
• Even if symptoms resolve, urgent evaluation is mandatory as recurrent torsion will occur 5
• Requires bilateral orchiopexy to prevent future episodes 1

Secondary Considerations (Less Likely Given Absent Cremasteric Reflex)

Epididymitis - the most common cause of testicular pain in adults (600,000 cases annually in the US) 1, but less likely here because:

• Typically presents with gradual onset pain, not intermittent positional pain 1
• Usually shows increased blood flow on Doppler, not decreased 1
• Cremasteric reflex is typically present 3
• May have abnormal urinalysis (though normal UA doesn't exclude it) 1
• Patient denies dysuria, fever, or urethritis symptoms 1

Torsion of testicular appendage - most common in prepubertal boys, not adults 1. Would show normal testicular perfusion with localized hyperemia 1.

Testicular mass/tumor - the palpable nodule raises this concern 6. However:

• Testicular cancer typically presents as painless enlargement 6
• Requires ultrasound to differentiate intra- vs extratesticular location 6
• If intratesticular mass confirmed, obtain tumor markers (AFP, β-HCG, LDH) before any intervention 6

Management Algorithm

If Torsion Confirmed or Highly Suspected Clinically:

1. Immediate urology consultation - do not wait for imaging if clinical suspicion is high 1, 7
2. Surgical exploration within 6-8 hours of symptom onset to achieve >90% testicular salvage rates 1, 5
3. Bilateral orchiopexy is mandatory during surgery due to bell-clapper deformity risk (present in 82% of intermittent torsion cases) 1

If Epididymitis Diagnosed:

• Bed rest, scrotal elevation, analgesics 1
• Appropriate antibiotics based on age and risk factors 1
• However, given absent cremasteric reflex, this diagnosis is less likely 3

If Intratesticular Mass Identified:

• Immediate urologic referral for radical inguinal orchiectomy 5
• Obtain tumor markers (AFP, β-HCG, LDH) before surgery 6
• Discuss sperm banking before any intervention in reproductive-age men 6, 5
• Never perform scrotal biopsy or scrotal incision - only inguinal approach is appropriate 5

Critical Pitfalls to Avoid

• Never delay surgical exploration for imaging when clinical suspicion for torsion is high 1, 5
• Do not rely on normal Doppler to exclude torsion - false-negative rate is 30% 1
• Do not use Prehn sign to differentiate torsion from epididymitis - it has poor sensitivity and specificity 5
• Do not dismiss intermittent symptoms - intermittent torsion requires the same urgent surgical management 5
• The median time to orchiectomy is 90 hours vs 12 hours for testicular salvage - every hour counts 2

Bottom Line

This patient needs urgent scrotal Doppler ultrasound today and same-day urology consultation. The absent cremasteric reflex with tender nodule and positional pain pattern creates high pretest probability for intermittent testicular torsion 2, 3. Even if ultrasound is normal, surgical exploration should be strongly considered given the clinical presentation 1. Testicular viability is critically time-dependent, with permanent ischemic damage occurring after 6-8 hours 1, 7.