What is the emergency management for an adolescent male with acute unilateral scrotal pain, nausea, vomiting, absent cremasteric reflex, and a high‑riding testis suggestive of testicular torsion?

Emergency Management of Testicular Torsion

Immediate urological consultation and urgent surgical exploration within 6-8 hours of symptom onset is mandatory for this adolescent with classic testicular torsion presentation, as testicular viability is critically time-dependent and imaging should never delay surgical intervention when clinical suspicion is high. 1

Immediate Actions Required

Do Not Delay Surgery for Imaging

• When clinical presentation includes acute unilateral scrotal pain, nausea/vomiting, absent cremasteric reflex, and high-riding testis, proceed directly to surgical exploration without waiting for ultrasound confirmation. 1, 2
• The 6-8 hour window from symptom onset determines testicular salvage—surgical outcomes deteriorate significantly after 12 hours. 1
• Testicular torsion occurs most frequently in adolescents with a bimodal peak in neonates and postpubertal boys, making this age group particularly high-risk. 1

While Awaiting Surgery

• Attempt manual detorsion in the emergency department while awaiting transfer or urological consultation. 2
• Manual detorsion technique: rotate the affected testis outward (like "opening a book") since most torsions occur medially. 3
• Ultrasound guidance can improve manual detorsion success rates if equipment and expertise are immediately available, but this should not delay definitive surgical management. 3
• Provide symptomatic therapy including analgesia and antiemetics. 2

Diagnostic Considerations (If Time Permits)

When Ultrasound May Be Appropriate

• Only obtain Duplex Doppler ultrasound if clinical suspicion is intermediate (TWIST score 1-5), never when suspicion is high. 1
• Ultrasound has variable sensitivity (69-96.8%) and false-negative rates up to 30%, particularly with partial torsion or early presentation. 1

Key Ultrasound Findings

• Decreased or absent testicular blood flow compared to contralateral side 1
• "Whirlpool sign" of twisted spermatic cord (96% sensitivity, most specific finding) 1, 3
• Enlarged heterogeneous hypoechoic testis with ipsilateral hydrocele and scrotal wall thickening 1

Critical Pitfall

• A normal ultrasound cannot exclude testicular torsion—proceed to surgical exploration if clinical suspicion remains high despite normal Doppler findings. 1, 2
• Partial torsion (<450 degrees) may show preserved arterial flow because venous obstruction occurs first, leading to false reassurance. 1

Surgical Management

Intraoperative Approach

• Perform inguinal or scrotal exploration with immediate detorsion of the affected testis. 1
• Assess testicular viability after detorsion—complete torsion >450 degrees results in absent arterial and venous flow. 1
• Perform bilateral orchiopexy (fixation of both testes) to prevent contralateral torsion, as the bell-clapper deformity is present bilaterally in 82% of cases. 1, 2

Fixation Technique Considerations

• While no single surgical technique has proven superiority, awareness of potential complications is essential. 4
• Inform patients and families during consent that testicular fixation carries risks of chronic scrotal pain and potential infertility, though these outcomes are poorly quantified in the literature. 1, 5
• Postoperative complications may include scrotal or stitch abscess formation. 6

Post-Surgical Care

• Bed rest, scrotal elevation, and analgesics until inflammation subsides. 1
• Follow-up to monitor for testicular atrophy (reported rates 9.1-47.5% in salvaged testes). 4

Medicolegal Considerations

• Inform the on-call consultant prior to surgical exploration—this is standard practice for urological emergencies. 5
• Document time of symptom onset, physical examination findings (particularly cremasteric reflex and testicular position), and time to surgical intervention. 1, 2
• The presence or absence of cremasteric reflex, while classically taught, is not perfectly reliable but remains an important clinical finding when absent. 2