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Sudden scrotal pain at night
A 15-year-old boy is woken at 4 a.m. by sudden, severe right scrotal pain and has vomited twice. He has no urinary symptoms and is not sexually active.
Step 1 of 4
The right testis lies high with a horizontal lie, and the right cremasteric reflex is absent.
What is the most likely diagnosis?
Correct answer: E
Sudden severe pain that wakes him, vomiting, a high-riding, horizontal testis and an absent cremasteric reflex is testicular torsion. Epididymitis starts gradually, with fever and dysuria, and the reflex is present (see testis and epididymis).
Show answer
E
Sudden severe pain that wakes him, vomiting, a high-riding, horizontal testis and an absent cremasteric reflex is testicular torsion. Epididymitis starts gradually, with fever and dysuria, and the reflex is present (see testis and epididymis).
Step 2 of 4
What is the most appropriate next step?
Correct answer: C
Torsion is a surgical emergency: salvage falls sharply after about 6 hours. With high suspicion, go straight to surgical exploration rather than delaying for ultrasound. Manual detorsion is only a temporary measure.
Show answer
C
Torsion is a surgical emergency: salvage falls sharply after about 6 hours. With high suspicion, go straight to surgical exploration rather than delaying for ultrasound. Manual detorsion is only a temporary measure.
Step 3 of 4
Which anatomic variant predisposes to torsion?
Correct answer: B
In the bell-clapper deformity the tunica vaginalis attaches too high on the cord, so the testis hangs free and can twist.
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B
In the bell-clapper deformity the tunica vaginalis attaches too high on the cord, so the testis hangs free and can twist.
Step 4 of 4
At surgery the testis is viable after detorsion. What else should be done?
Correct answer: A
Detorsion is followed by bilateral orchiopexy — the other testis is fixed as well.
Show answer
A
Detorsion is followed by bilateral orchiopexy — the other testis is fixed as well.
Key points
- Sudden pain + high horizontal testis + absent cremasteric reflex → torsion → OR, don't wait for ultrasound.
- Gradual pain, fever, dysuria, reflex present, Prehn sign → epididymitis.
- Bell-clapper deformity; fix both sides.
Study: Testis and epididymis, Spermatic cord