Physical Exam Findings in Testicular Torsion
In an adolescent male with sudden severe unilateral scrotal pain, the absence of the cremasteric reflex combined with testicular retraction and a negative Prehn sign are the most critical physical exam findings that indicate testicular torsion. 1, 2
Key Physical Examination Findings
Most Specific Clinical Signs
Absent cremasteric reflex is the single most reliable physical exam finding, strongly associated with testicular torsion (p < 0.0001) 1, 2, 3, 4
- The cremasteric reflex is tested by stroking the inner thigh; normally this causes the ipsilateral testicle to rise
- Absence of this reflex has high sensitivity and specificity for torsion
Testicular retraction (high-riding testicle) is highly predictive of torsion (p < 0.0001) 1, 2, 3, 4
- The affected testicle sits higher in the scrotum than the contralateral side
- This occurs due to shortening of the twisted spermatic cord
Negative Prehn sign distinguishes torsion from epididymitis 1, 3
- Pain is NOT relieved (and may worsen) when the testicle is elevated
- In contrast, epididymitis typically shows pain relief with elevation (positive Prehn sign)
Additional Supportive Findings
- Scrotal swelling is present in 92.2% of cases 2
- Pain on palpation occurs in 93.5% of cases 2
- Scrotal hyperemia (redness) is seen in 84.4% of cases 2
- Abnormal testicular lie with horizontal orientation may be noted 1
Visual Inspection Findings
- Markedly enlarged scrotum with bluish hue signifies vascular compromise and possible hemorrhagic necrosis, indicating advanced torsion 1
- Scrotal wall thickening and edema are common 1
- Ipsilateral hydrocele may be present as a reactive finding 1
Critical Clinical Pitfalls
Normal urinalysis does NOT exclude testicular torsion 1
- Unlike epididymitis, torsion typically has normal urinalysis
- Do not be falsely reassured by absence of pyuria or bacteriuria
Transillumination may be falsely positive due to reactive hydrocele or severe scrotal edema 1
- Do not let positive transillumination delay surgical consultation
Nausea and vomiting are common associated symptoms that support the diagnosis 3, 4
Immediate Action Required
If clinical examination reveals absent cremasteric reflex, high-riding testicle, and negative Prehn sign, immediate urological consultation and surgical exploration are indicated WITHOUT delay for imaging studies. 1, 4 The critical window is 6-8 hours from symptom onset to prevent permanent testicular loss 1, 4. When clinical suspicion is high based on physical exam, do not postpone surgery to obtain ultrasound confirmation 4.