In an adolescent male with sudden unilateral scrotal pain, nausea/vomiting, absent cremasteric reflex, and a high‑riding testis, how can testicular torsion be distinguished from orchitis?

Distinguishing Testicular Torsion from Orchitis in Adolescent Males

In an adolescent male presenting with sudden unilateral scrotal pain, nausea/vomiting, absent cremasteric reflex, and a high-riding testis, testicular torsion is the diagnosis until proven otherwise and requires immediate urological consultation without delay for imaging. 1

Key Clinical Distinguishing Features

Testicular Torsion (The Presentation Described)

• Abrupt onset of severe scrotal pain is the hallmark of testicular torsion, contrasting sharply with the gradual pain onset seen in epididymitis/orchitis 1, 2
• Absent cremasteric reflex is the most accurate clinical sign of testicular torsion and is a critical distinguishing feature 3
• High-riding testis results from shortening of the spermatic cord due to twisting 1
• Nausea and vomiting are common systemic symptoms that accompany testicular torsion but are less frequent in orchitis 4, 2
• Negative Prehn sign (pain is NOT relieved when the testicle is elevated) distinguishes torsion from epididymitis, where elevation typically provides relief 1
• Normal urinalysis is typical in testicular torsion, whereas orchitis/epididymitis may show pyuria or bacteriuria 1

Orchitis/Epididymo-orchitis (The Alternative Diagnosis)

• Gradual onset of pain over hours to days is characteristic, not the sudden severe pain of torsion 1, 5
• Cremasteric reflex is typically present in orchitis, unlike the absent reflex in torsion 3
• Abnormal urinalysis with pyuria and/or bacteriuria may be present, though normal urinalysis does not exclude the diagnosis 1, 6
• History of urinary tract infection or prostatitis often precedes epididymitis in adults 5
• Positive Prehn sign (pain relief with testicular elevation) suggests epididymitis rather than torsion 1

Diagnostic Imaging When Clinically Indicated

Critical caveat: If clinical suspicion for testicular torsion is high based on the presentation described (sudden pain, absent cremasteric reflex, high-riding testis), proceed directly to surgical exploration without imaging, as testicular viability is compromised if not treated within 6-8 hours. 1, 2

Doppler Ultrasound Findings

For Testicular Torsion:

• Decreased or absent blood flow to the affected testicle compared to the contralateral side 1, 5
• "Whirlpool sign" of the twisted spermatic cord on grayscale imaging (96% sensitivity) 1
• Enlarged heterogeneous testis that may appear hypoechoic 1
• Ipsilateral hydrocele and scrotal skin thickening 1

For Orchitis/Epididymo-orchitis:

• Increased blood flow (hyperemia) on color Doppler to the epididymis and testis 1, 5
• Enlarged epididymis with increased vascularity 1
• Scrotal wall thickening and possible hydrocele 1

Important Imaging Limitations

• Color Doppler has variable sensitivity (69-96.8%) for testicular torsion, meaning false-negative evaluations occur in up to 30% of cases 1
• Partial torsion presents the greatest diagnostic challenge because arterial flow may persist while venous obstruction occurs first, potentially leading to false-negative Doppler studies 1
• Power Doppler is more sensitive for detecting low-flow states and is particularly useful in prepubertal boys who normally have reduced intratesticular blood flow 1

Critical Clinical Pitfalls to Avoid

• Never delay surgical exploration for imaging when clinical presentation strongly suggests torsion (as in the case described) 1, 2
• Significant overlap exists in clinical presentation between different causes of acute scrotal pain, making diagnosis challenging 1
• Orchitis can rarely precipitate testicular torsion due to testicular enlargement and inflammation, so close follow-up is essential even when orchitis is diagnosed 7
• Normal urinalysis does not exclude testicular torsion, as pyuria may be present in up to 30% of torsion cases 1
• False-negative Doppler evaluations can occur with partial torsion, spontaneous detorsion, or early presentation within the first few hours 1

Management Algorithm

For the presentation described (sudden pain, absent cremasteric reflex, high-riding testis):

1. Immediate urological consultation without delay 1, 2
2. Surgical exploration and detorsion within 6-8 hours of symptom onset to prevent permanent ischemic damage 1, 2
3. Bilateral orchiopexy during surgery to prevent contralateral torsion, as the bell-clapper deformity is often bilateral 1

If orchitis is definitively diagnosed (gradual onset, present cremasteric reflex, increased flow on Doppler):

1. Bed rest and scrotal elevation 1
2. Analgesics for pain control 1
3. Appropriate antibiotic therapy based on age and risk factors 1
4. Close follow-up to ensure resolution and monitor for potential complications 7

Age-Specific Considerations

• Testicular torsion has a bimodal distribution with peaks in neonates and postpubertal boys, making it the primary concern in adolescents 1, 8
• Epididymitis/orchitis is more common in adults over 25 years, representing approximately 600,000 cases annually in the United States 1
• In adolescents, testicular torsion must be excluded first before considering other diagnoses 1, 2