The patient in the above vignette is experiencing a case of testicular torsion. In any suspected case, emergent surgical exploration is the treatment of choice, bypassing all other modalities of confirmation or imaging.
Testicular torsion is a twisting of the testicle around its vascular stalk. This twisting results in ischemia. Peripubertal patients are the most often afflicted individuals, although it can happen in males of any age. Torsion threatens the viability of the testis and is a urological emergency. Symptoms include acute onset testicular pain with edema, nausea, and vomiting. Tender testicles in a transverse lie in addition to an absent cremasteric reflex are noted on physical examination. Surgical exploration with decompression and excision of the infarcted testicle is indicated and should not be delayed by imaging studies in patients that present with a compatible clinical picture.
Sharp et al. report on the diagnosis, evaluation, and management of testicular torsion. The incidence of this specific pathology is approximately 3.8 per 100,000 males younger than 18 years annually. Testicular torsion is a clinical diagnosis and typically presents with severe, acute, unilateral scrotal pain, nausea, and vomiting. Prompt diagnosis is necessary because there is a four-to-eight-hour window after onset of symptoms before permanent ischemic damage occurs.
Takure et al. discuss treatment options for testicular torsion cases. A total of 169 cases of testicular torsion were analyzed from patients aging in range from 9 months to 45 years old. Interestingly, about 62% of cases were found in men older than 21 years of age. Seventy-one percent of cases underwent bilateral orchiopexy, while nineteen percent had orchiectomy and ten percent had unilateral orchidopexy. There is still a necessity for health education concerning this devastating injury.
Illustration A depicts an artist's rendering of an individual before and after surgical decompression of testicular torsion. Illustration B is an overview image describing the cremasteric reflex.
Answers 1,3,4: Pelvic radiographs, MRIs, and CT scans have no role in the evaluation of the acute scrotum.
Answer 2: Although ultrasound is considered the imaging test of choice in patients with acute scrotum, it should not delay surgical intervention in patients with suspected torsion.
Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15;88(12):835-40.
PMID:24364548 (Link to Abstract)
Takure AO, Shittu OB, Adebayo SA, Okeke LO, Olapade-Olaopa EO. Torsion of the Testis and factors that determine the choice of Orchidectomy and unilateral Orchidopexy. Niger Postgrad Med J. 2013 Sep;20(3):197-202.
PMID:24287750 (Link to Abstract)