Scrotal pain and testicular torsion: SAQ

This boy has high-probability testicular torsion. The sudden severe unilateral scrotal pain, the high-riding horizontally lying testis, the absent cremasteric reflex, and the vomiting form the classic picture, and the pain began only 70 minutes ago, which places him well inside the 6-hour salvage window. The clear urine does not exclude torsion, and the cardinal signs do not fit a mimic such as epididymitis or torsion of the appendix testis. The working diagnosis is torsion, and the priority is to move him to theatre without imaging delay. ^[1]

Question 1 (10 marks)

Outline your immediate assessment and management of this boy, including how you would use the TWIST score and how you would decide between theatre and imaging. ^[2]

I would state at the outset that this boy has torsion until proven otherwise, and I would record the exact time the pain began, because the salvage clock starts there. The assessment is a focused scrotal examination within minutes, confirming the high-riding horizontal testis and the absent cremasteric reflex, and I would examine the abdomen because referred abdominal pain from a hidden torsion is a classic trap. I would apply the TWIST score, which gives one point each for testicular swelling, a hard testis, an absent cremasteric reflex, nausea or vomiting, and a high-riding testis, for a maximum of five. This boy scores 5, with the swelling, the absent cremasteric reflex, the vomiting, and the high-riding testis, which is the high-risk band. ^[5]

A high-risk TWIST score means he goes straight to surgical exploration without imaging, and the systematic review and meta-analysis by Qin and Qu confirmed that high-risk boys should proceed to theatre. Colour Doppler ultrasound is reserved for the intermediate-risk boy with a score of 3 to 4, and it must never delay exploration in a high-probability presentation. I would make the boy nil by mouth, secure intravenous access, give weight-adjusted analgesia with paracetamol and an opioid for the severe pain, and call the surgeon the moment torsion is on the differential. ^[2]

The aim is to have him in theatre inside the 6-hour window, and the salvage rate is 90 to 100 percent when exploration occurs within 6 hours of pain onset, falling to about 50 percent from 6 to 12 hours. I would explain to the boy and his parents that the cord to the testis has twisted and cut off the blood supply, that the testis can be saved if it is untwisted quickly, and that he needs an urgent operation. If the surgeon is delayed, I would consider manual detorsion, rotating the testis laterally to open the book, as a painful bridge while awaiting theatre, but he would still proceed to definitive fixation. ^[1]