What is the emergent management of suspected testicular torsion in an adolescent male with sudden severe unilateral scrotal pain, a high‑riding testis, absent cremasteric reflex, and possible nausea or vomiting?

Emergent Management of Testicular Torsion

Testicular torsion is a surgical emergency requiring immediate urological consultation and surgical exploration within 6-8 hours of symptom onset—do not delay surgery for imaging if clinical suspicion is high. 1

Immediate Clinical Assessment

When an adolescent male presents with sudden severe unilateral scrotal pain, evaluate these key clinical features:

• High-riding testis with abnormal lie indicates torsion until proven otherwise 1
• Absent cremasteric reflex is a critical finding, though its presence does not exclude torsion 2
• Negative Prehn sign (pain NOT relieved with testicular elevation) distinguishes torsion from epididymitis 1
• Nausea and vomiting are common associated symptoms 3, 2
• Abrupt onset of severe pain differentiates torsion from the gradual onset typical of epididymitis 1

Risk Stratification

Use the TWIST score for intermediate clinical suspicion cases (score 1-5) to determine urgency of imaging versus immediate surgical exploration 1. However, high clinical suspicion (score >5) mandates immediate surgical exploration without imaging 1, 3.

Diagnostic Imaging Protocol (Only for Intermediate Suspicion)

Duplex Doppler ultrasound is first-line imaging when clinical suspicion is intermediate 1:

Key Ultrasound Findings for Torsion:

• Decreased or absent testicular blood flow compared to contralateral side (sensitivity 69-96.8%, specificity 87-100%) 1
• "Whirlpool sign" of twisted spermatic cord (96% sensitivity, most specific finding) 1, 4
• Enlarged heterogeneous testis appearing hypoechoic 1
• Ipsilateral hydrocele and scrotal wall thickening 1

Critical Imaging Pitfalls:

• False-negative Doppler occurs in 30% of cases, particularly with partial torsion (<450 degrees) or spontaneous detorsion 1
• Partial torsion may show persistent arterial flow because venous obstruction occurs first, making diagnosis challenging 1
• Power Doppler is superior to color Doppler for detecting low-flow states, especially in prepubertal boys 1
• Always compare to contralateral testis as internal control 1

Never let normal ultrasound findings delay surgery when clinical suspicion remains high—proceed directly to surgical exploration 1, 2.

Definitive Management Algorithm

Immediate Actions:

1. Obtain urgent urology consultation immediately upon suspicion 1, 3
2. Proceed to surgical exploration within 6-8 hours of symptom onset to prevent permanent ischemic damage 1, 3
3. Do NOT delay surgery for imaging if clinical presentation is classic 3

Surgical Procedure:

• Scrotal or inguinal exploration with detorsion of affected testis 1
• Assessment of testicular viability after detorsion 1
• Bilateral orchiopexy is mandatory to prevent contralateral torsion, as 82% of patients have bell-clapper deformity bilaterally 1
• Orchiectomy if testis is nonviable (occurs in 42% of cases due to delayed presentation) 3

Manual Detorsion (Temporizing Measure Only):

While awaiting surgery, attempt manual detorsion by rotating the testis laterally (like "opening a book") 2. This is a temporizing measure and does not replace surgical exploration 5.

Time-Critical Considerations

Testicular salvage rates are time-dependent 1, 3:

• <6 hours: High salvage rate
• 6-8 hours: Critical window before permanent damage 1
• >12 hours: Significantly decreased salvage rates 1
• >24 hours: Near-certain testicular loss 3

Post-Operative Care

After successful detorsion and bilateral orchiopexy 1:

• Bed rest with scrotal elevation 1
• Analgesics until inflammation subsides 1
• Monitor for complications including testicular atrophy and subfertility 5, 6

Common Pitfalls to Avoid

• Do not rely on normal urinalysis to exclude torsion—urinalysis is typically normal in torsion 1
• Do not delay surgery for imaging when clinical presentation is classic 3
• Do not assume torsion is excluded based on normal Doppler ultrasound alone 1, 2
• Do not forget bilateral orchiopexy—the contralateral testis is at equal risk 1
• Do not dismiss intermittent pain—intermittent torsion with spontaneous detorsion can occur and still requires bilateral orchiopexy 1

Age-Specific Considerations

Testicular torsion has a bimodal distribution with peaks in neonates and postpubertal boys (12-18 years), though it can occur at any age 1, 4, 2. In adolescents, torsion is more common than epididymitis, making surgical exploration the safer approach when diagnosis is uncertain 1.