Scrotal pain and testicular torsion: Case

This boy has high-probability testicular torsion. The sudden severe unilateral pain that woke him from sleep, the vomiting, the high-riding horizontally lying testis, and the absent cremasteric reflex form the classic picture, and a TWIST score of 5 places him in the high-risk band. The 90-minute duration places him well inside the 6-hour salvage window, which makes the speed of the decision and referral determinant of whether he keeps his testis. ^[1]

Clinical findings and assessment

The key clinical findings are the absent cremasteric reflex on the right, the single most sensitive sign of torsion, the high-riding horizontal lie, the swelling and tenderness, and the vomiting. The clear urinalysis does not exclude torsion, and the cardinal signs do not fit a mimic. The TWIST score is 5, with one point each for the testicular swelling, the hard and tender testis, the absent cremasteric reflex, the vomiting, and the high-riding testis, which is the high-risk band confirmed by the systematic review and meta-analysis of Qin and Qu. ^[5]

The differential of the acute scrotum is short but high-stakes. Testicular torsion sits beside the torsion of the appendix testis, which is gradual and prepubertal with a blue dot sign and a normal lie, and the acute epididymitis, which is gradual with fever, dysuria, pyuria, and a preserved cremasteric reflex. The sudden severe onset, the absent cremasteric reflex, the high-riding testis, and the vomiting make torsion the working diagnosis, and the only safe stance is that torsion is present until excluded by exploration. ^[2]