Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: Testicular Torsion in an Adolescent Male

Patient Demographics

  • Age: 16 years
  • Sex: Male
  • Occupation: High school student

Chief Complaint

"My left testicle hurts really bad and I feel like I'm going to throw up."

History of Present Illness

The patient presents to the emergency department with sudden onset of severe left scrotal pain that began approximately 3 hours ago while he was playing basketball. The pain started abruptly without any direct trauma to the groin. He describes the pain as constant and severe, rated 9/10, with radiation to the left lower abdomen. He has vomited twice since the pain began. He denies dysuria, urinary frequency, fever, or penile discharge. He has no prior history of similar episodes. The patient's mother notes that he has been otherwise healthy with no significant medical history.

Vital Signs

  • Temperature: 98.8 degrees F (37.1 degrees C)
  • Blood pressure: 138/82 mmHg
  • Heart rate: 98 bpm
  • Respiratory rate: 18/min
  • Oxygen saturation: 99% on room air

Physical Examination

General: Adolescent male in obvious distress, lying still on the stretcher, appears nauseated Abdomen: Soft, mild tenderness in left lower quadrant, no peritoneal signs Genitourinary:

  • Left testicle: High-riding within the scrotum with horizontal (transverse) lie
  • Significant swelling and erythema of the left hemiscrotum
  • Exquisite tenderness to palpation of the left testicle
  • Cremasteric reflex: Absent on the left, present on the right
  • No relief of pain with testicular elevation (negative Prehn sign)
  • Right testicle: Normal position, non-tender, normal lie
  • No penile discharge or lesions
  • No inguinal lymphadenopathy

Diagnostic Studies

Urinalysis: Clear, no blood, no WBCs, no bacteria Scrotal Doppler Ultrasound:

  • Left testicle: Absent intratesticular blood flow on color Doppler
  • Right testicle: Normal blood flow
  • No hydrocele or varicocele identified
  • Findings consistent with left testicular torsion

Diagnosis

Left testicular torsion - urologic emergency requiring immediate surgical intervention

Management

Immediate Actions:

  1. NPO status established
  2. IV access obtained, normal saline bolus initiated
  3. Pain management with morphine 4 mg IV
  4. Antiemetic ondansetron 4 mg IV
  5. Emergent urology consultation placed

Manual Detorsion Attempted:

  • "Open the book" maneuver attempted (lateral rotation of the left testicle)
  • Patient reported partial pain relief after external rotation
  • Repeat Doppler showed improved but not normal blood flow
  • Decision made to proceed directly to surgical exploration

Surgical Management:

  • Emergent scrotal exploration within 4 hours of symptom onset
  • Intraoperative findings: 540-degree torsion of the left spermatic cord
  • Detorsion performed with return of normal color to the testicle
  • Bilateral orchiopexy performed (both testicles fixed to the scrotal wall)
  • Testicle viable, no orchiectomy required

Post-Operative Course:

  • Uncomplicated recovery
  • Discharged on post-operative day 1
  • Follow-up in urology clinic in 2 weeks

Clinical Pearl

The classic presentation of testicular torsion includes sudden onset of severe unilateral scrotal pain, nausea/vomiting, a high-riding testicle with horizontal lie, and an absent cremasteric reflex. The salvage rate is nearly 100% when detorsion occurs within 6 hours, drops to approximately 20% at 12 hours, and approaches 0% after 24 hours. Imaging should never delay surgical exploration when clinical suspicion is high. Bilateral orchiopexy is performed because the contralateral testicle has the same anatomic predisposition (bell-clapper deformity) in approximately 80% of cases.

Clinical Image

Image Description: Scrotal Doppler ultrasound demonstrating absent blood flow to the affected testicle on the left compared with normal blood flow to the contralateral testicle on the right, consistent with testicular torsion.

Attribution: Image from Wikimedia Commons, Category: Ultrasound images of testicular torsion. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/Category:Ultrasound_images_of_testicular_torsion

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