A 15-year-old boy complains of sharp, radiating left testicular pain, which started while playing basketball 1 hour ago. He denies specific trauma, but tells you he first noted the pain while running. He also says that he was recently treated for epididymitis “with two antibiotics” but admits that he did not finish them. Physical examination reveals a tender, slightly enlarged left testicle lying in the horizontal plane. There is no cremasteric reflex on the left, but it is present on the right. When you look at his scrotum, you do not see a “blue dot” sign. Your next step is to:
Place him in the supine position, administer parenteral analgesics, and observe for changes.
Hospitalize him for treatment with intravenous antibiotics.
Counsel him on the importance of taking medications as prescribed and discharge him with scrotal elevation and oral antibiotics.
Consult urology and obtain consent for surgery.
Place ice packs on the area for 5 minutes out of every 20 minutes.
Although torsion may occur at any age, it is most common in the first year of life and at puberty. It is more common in undescended testis and should be considered in a patient with a painful inguinal mass and an empty scrotum. The onset is usually acute and frequently follows physical activity. The initial effect of torsion is venous engorgement, which leads to edema, pain, and tenderness. Depending on the extent of vascular compromise, it can progress to necrosis and infarction and attempts at detorsion should be made as soon as possible. Emergent urologic consultation should be obtained and manual detorsion can be attempted after appropriate analgesia. Even if successful, the patient still requires definitive surgical care. In cases where the diagnosis is in doubt, a testicular ultrasound with color Doppler flow is the test of choice at most institutions. The differential diagnosis of a young male patient with acute testicular pain is testicular torsion, infection, trauma, tumor with hemorrhage, and torsion of the appendices of the testis or epididymis. The last may be diagnosed clinically with reasonable certainty if a “blue dot” sign (indicative of venous engorgement) is seen through the scrotal skin.