Reproductive · Year 2 · from Reproductive
Case 2: Testicular Torsion
Clinical Image
Source: Radiopaedia - Testicular torsion - CC BY-NC-SA 3.0
Case Presentation
A 16-year-old male is brought to the emergency department at 3 AM with sudden onset of severe left testicular pain that awoke him from sleep 4 hours ago. He reports nausea and one episode of vomiting. He denies fever, dysuria, urethral discharge, or recent trauma. Physical examination reveals an anxious adolescent in obvious distress. The left hemiscrotum is edematous and erythematous. The left testis is exquisitely tender, high-riding (elevated compared to the right), and has a horizontal lie. The cremasteric reflex is absent on the left (stroking the inner thigh does not cause testicular elevation). The right testis is normal. Given the high clinical suspicion, the urology team is called immediately for emergency surgical exploration while a scrotal ultrasound with Doppler is performed, which confirms absent blood flow to the left testis. At surgery, the left spermatic cord is found to be twisted 540 degrees. Upon detorsion, the testis initially appears dusky but regains pink coloration after warm saline application, indicating viability. Bilateral orchiopexy is performed to prevent recurrence. The patient recovers well with preservation of the left testis.
Key Learning Points
- Testicular torsion is a urologic emergency; testicular salvage rates are approximately 90% if surgery occurs within 6 hours, dropping to near 0% after 24 hours
- Classic presentation includes sudden onset of severe testicular pain, nausea/vomiting, high-riding testis, horizontal lie, and absent cremasteric reflex
- Imaging should not delay surgical exploration when clinical suspicion is high; a normal ultrasound does not exclude torsion
- Bilateral orchiopexy is performed because the anatomic predisposition (bell-clapper deformity) is often bilateral