What is the most likely additional physical examination finding in a 19-year-old sexually active man with a history of Neisseria gonorrhoeae, presenting with acute onset of severe scrotal pain, a high-riding swollen mass on the right, and minimal relief with ibuprofen (nonsteroidal anti-inflammatory drug), after participating in a soccer game?

Testicular Torsion: Absent Cremasteric Reflex

The most likely additional physical examination finding in this patient is absent elevation of the right testicle with stroking of the ipsilateral thigh (Answer A), representing an absent cremasteric reflex—a key distinguishing feature of testicular torsion. 1

Clinical Presentation Analysis

This 19-year-old presents with the classic triad for testicular torsion:

• Acute onset severe scrotal pain (6 hours duration, started during physical activity) 1
• High-riding testicle on the affected right side compared to the normally positioned left testicle 1
• Age in the peak incidence range (postpubertal adolescent/young adult in the bimodal distribution) 1

The history of recurrent gonorrhea is a red herring—while it suggests risk for epididymitis, the acute onset and high-riding testicle strongly favor torsion over the gradual onset typical of epididymitis. 1

Understanding the Cremasteric Reflex

The absent cremasteric reflex (negative Prehn sign) is pathognomonic for testicular torsion. 1 When you stroke the inner thigh, the cremasteric muscle normally contracts and elevates the ipsilateral testicle. In torsion, this reflex is absent because the twisted spermatic cord disrupts the neurovascular bundle. 2

Multivariate analysis demonstrates that absence of the ipsilateral cremasteric reflex is the most consistent predictive factor for testicular torsion (P < 0.001), along with nausea/vomiting and scrotal skin changes. 2

Why the Other Options Are Incorrect

• Option B (enlargement with Valsalva) suggests an inguinal hernia, which doesn't present with acute severe pain and a high-riding testicle 1

• Option C (size increase when standing) indicates a varicocele, which presents as a "bag of worms" sensation and doesn't cause acute severe pain 1

• Option D (pain reduction with elevation - positive Prehn sign) is characteristic of epididymitis, not torsion. This is the opposite of what occurs in testicular torsion. 1, 3

• Option E (transillumination) suggests a hydrocele or spermatocele, which are painless conditions that don't present acutely 1

Critical Management Considerations

This patient requires immediate urological consultation and surgical exploration within 6-8 hours of symptom onset (already at 6 hours). 1, 4

Key Clinical Pitfalls to Avoid:

• Do not delay surgery for imaging if clinical suspicion is high. 4 The physical examination findings (high-riding testicle, acute severe pain, absent cremasteric reflex) are sufficient for surgical exploration. 1

• Do not be falsely reassured by the sexual history. While this patient has STI risk factors, epididymitis presents with gradual onset pain, not the acute presentation seen here. 1

• If ultrasound is performed, remember that 30% of cases can have false-negative Doppler studies, particularly with partial torsion where arterial flow may persist. 1 The whirlpool sign on grayscale has 96% sensitivity and should be specifically sought. 1

• Testicular salvage rates decline precipitously after 6-8 hours, with permanent ischemic damage occurring beyond this window. 1, 4 This patient is already at the critical threshold.

The combination of acute onset, high-riding testicle, and absent cremasteric reflex makes testicular torsion the diagnosis until proven otherwise, warranting immediate surgical intervention. 1, 2