Scrotal and testicular complaints — KFP-style written assessment

KFP 1 (10 marks)

A 14-year-old is brought in at 7 am with three hours of severe left testicular pain beginning during sleep. He vomited twice. The left testis is swollen, high-riding and exquisitely tender; the cremasteric reflex is absent.^{[4] [7]}

1. Score this presentation and state the immediate action. (3) ^[4]
2. The on-call surgeon requests ultrasound first. What are the clinical rules around imaging here? (4) ^{[9] [7]}
3. At theatre, the testis looks dusky but pinkens after detorsion. What surgery follows and why both sides? (3) ^[11]

Model answers

1. TWIST 7/7: swelling 2 + hard testis 2 + high-riding 1 + absent cremasteric reflex 1 + vomiting 1. This is the high-risk Barbosa band (5-7), which carried specificity 0.975 for torsion in meta-analysis — direct surgical exploration without imaging delay. ^[4]
2. Doppler ultrasound performs well pooled (sensitivity 95.3%, specificity 98.3%), so a clearly normal study can help in genuinely equivocal cases. But two rules protect patients: imaging must never delay theatre when suspicion is high, and a normal scan never overrides a convincing story because intermittent torsion detorses between scans. Orchiectomy risk climbs steeply beyond ~6.5 hours from onset; median onset-to-surgery was 5.5 hours among salvaged testes versus 51.1 hours among lost ones. ^{[9] [7]}
3. Bilateral orchidopexy. The bell-clapper anatomical predisposition is bilateral, so the contralateral testis shares re-torsion risk; fixation prevents future torsion on either side. ^[11]