What are the typical presentation, diagnostic approach, and emergent treatment for testicular torsion in adolescent males?

Testicular Torsion: Clinical Overview

Immediate Recognition and Action

Testicular torsion is a surgical emergency requiring immediate urological consultation and surgical exploration within 6-8 hours of symptom onset to prevent permanent testicular loss. 1, 2 Any delay in surgical intervention beyond this critical window dramatically increases the risk of orchiectomy, with testicular salvage rates dropping precipitously after 12 hours. 1

Clinical Presentation

Classic Features in Adolescents

Testicular torsion demonstrates a bimodal age distribution, with peaks in neonates and postpubertal boys, making adolescent males the highest-risk population. 1, 2 The typical presentation includes:

• Sudden onset of severe, unilateral scrotal pain (not gradual—this distinguishes it from epididymitis) 1, 2
• Nausea and vomiting accompanying the acute pain 3
• Negative Prehn sign (pain is NOT relieved when elevating the testicle) 1, 2
• Absent cremasteric reflex on physical examination 3
• High-riding testicle with abnormal lie 3
• Firm, tender testicle on palpation 2

Critical Pitfall: Age-Related Delay

Patients under 18 years old present with a median delay of 20 hours versus only 4 hours in adults over 18, resulting in a 44% orchiectomy rate in adolescents compared to 8% in adults. 4 This age group represents over 90% of all orchiectomies performed for torsion. 4

Diagnostic Approach

When Clinical Suspicion is High

If history and physical examination strongly suggest torsion, proceed immediately to surgical exploration without imaging. 3 Do not delay surgery to obtain ultrasound when clinical findings are compelling—testicular viability depends on the 6-8 hour window. 1, 2

When Clinical Suspicion is Intermediate (TWIST Score 1-5)

Obtain urgent Duplex Doppler ultrasound of the scrotum, which should include: 1

• Grayscale examination to assess testicular homogeneity, identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity), and evaluate for enlarged heterogeneous testis, ipsilateral hydrocele, and scrotal wall thickening 1
• Color Doppler assessment showing decreased or absent blood flow to the affected testicle (96-100% sensitivity) 1
• Power Doppler for enhanced detection of low-flow states, particularly useful in prepubertal boys with normally reduced intratesticular blood flow 1
• Spectral Doppler analysis at upper, mid, and lower poles to detect regional flow variations, looking for diminished arterial velocity, decreased/absent diastolic flow, or reversed diastolic flow 1
• Comparison to contralateral testis as an internal control 1

Understanding Ultrasound Limitations

Color Doppler ultrasound has variable sensitivity (69-96.8%) and specificity (87-100%) for testicular torsion. 1 False-negative evaluations occur in 30% or more of cases, particularly with partial torsion, spontaneous detorsion, or early presentation. 1 Complete torsion (>450 degrees) shows absent arterial and venous flow, but partial torsion presents the greatest diagnostic challenge because venous obstruction occurs first, allowing arterial flow to persist initially. 1

When clinical suspicion remains high despite normal Doppler findings, proceed immediately to surgical exploration—do not let reassuring imaging delay definitive treatment. 1

Differential Diagnosis by Age

Adolescents and Young Adults

The three most common causes of acute scrotal pain in this population are: 1, 2

1. Testicular torsion (surgical emergency): Sudden severe pain, negative Prehn sign, decreased/absent flow on Doppler 1, 2
2. Epididymitis/epididymo-orchitis: Gradual onset, positive Prehn sign (pain relief with elevation), increased blood flow on Doppler, may have abnormal urinalysis 1, 2
3. Torsion of testicular appendage: Normal testicular perfusion with localized hyperemia near the appendage, "blue dot sign" visible in only 21% of cases 1, 2

Key Distinguishing Features

• Normal urinalysis does NOT exclude testicular torsion 1
• Trauma history can be a red herring—progressive worsening pain with systemic symptoms points to torsion, not simple traumatic injury 2
• Epididymitis is most common in sexually active young adults (caused by C. trachomatis or N. gonorrhoeae) or men >35 years (enteric organisms) 5

Surgical Management

Definitive Treatment

Immediate urological consultation and prompt surgical exploration are mandatory for confirmed or highly suspected testicular torsion. 1, 2 The surgical procedure involves: 1

• Inguinal or scrotal exploration with detorsion of the affected testis
• Assessment of testicular viability after detorsion
• Bilateral orchiopexy to prevent recurrence (the Bell clapper deformity is found in 82% of patients with intermittent torsion and mandates contralateral fixation) 1, 6

Time-Critical Outcomes

• Within 6-8 hours: Optimal window for testicular salvage 1, 2, 3
• Within 12 hours: Surgical outcomes remain favorable 1
• Beyond 12 hours: Dramatically increased risk of orchiectomy 1, 3

Common Clinical Pitfalls

Do NOT:

• Start antibiotics for presumed epididymitis when torsion is in the differential—this delays correct diagnosis and treatment 2
• Delay surgical consultation for imaging when clinical suspicion is high—this risks testicular loss 2
• Rely solely on ultrasound to exclude torsion—false negatives occur in up to 30% of cases 1
• Assume normal urinalysis excludes torsion—it does not 1
• Be reassured by trauma history—torsion can occur after minor trauma 2

DO:

• Treat any acute scrotal pain as a potential surgical emergency until torsion is excluded 1, 2
• Use the contralateral testicle as an internal control during ultrasound evaluation 1
• Proceed to surgical exploration when clinical suspicion is high, regardless of imaging findings 1, 3
• Target adolescents for health education about early evaluation of scrotal pain, as they represent the highest-risk group for testicular loss 4

Post-Operative Care

Following successful detorsion and orchiopexy, management includes bed rest, scrotal elevation, and analgesics until inflammation subsides. 1