← Diagnosis and Management Guides
Testicular Torsion
Key considerations: Testicular torsion (surgical emergency), Fournier gangrene
Cannot miss
- Testicular torsion (surgical emergency)
- Fournier gangrene
Likely diagnoses
- Testicular torsion
- Epididymitis
- Torsion of testicular appendage
- Hernia
- Orchitis
Red flags
- Acute onset scrotal pain
- Absent cremasteric reflex
- High-riding testis
- Age <25
Workup
- history: Acute onset scrotal pain, nausea/vomiting, prior episodes, duration (<6hr for best salvage); exam: High-riding testis, transverse lie, absent cremasteric reflex, Prehn sign (unreliable); labs: Urinalysis (usually normal in torsion, positive in epididymitis); imaging: Doppler ultrasound only if diagnosis uncertain AND does NOT delay surgery; If clinical suspicion high: go directly to OR; bedside: Cremasteric reflex assessment
Management
- immediate: Manual detorsion: "open the book" (medial to lateral rotation); If successful: still needs surgical exploration and orchiopexy; Emergent urology consult for surgical exploration; general: Bilateral orchiopexy (fix both testes); Salvage rates: 90-100% if <6hr, <10% if >24hr
Disposition
- admit: All confirmed or suspected torsion for surgery; discharge: Only epididymitis or torsion of appendage with urology follow-up; consults: Urology — emergent
Clinical pearls
- The absent cremasteric reflex is the single most sensitive finding for torsion (sensitivity ~99%)
- Do NOT delay surgery for ultrasound if clinical suspicion is high — time = testicle
- 6-hour window for best salvage — this is a true time-critical emergency
Source and review
- AUA Scrotal Pain Guidelines 2018. Last reviewed: 2024-11-01