Thirty hours of scrotal pain with 'normal' Doppler flow
A 16-year-old boy is brought to the emergency department at 02:00 with left scrotal pain that began 30 hours earlier while playing football and woke him from sleep. He vomited once and was given paracetamol by his mother. On examination the left hemiscrotum is swollen and tender, the testis lies high and horizontal, and the cremasteric reflex is absent. There is no dysuria and no urethral discharge. Temperature 37.4 °C. Colour Doppler ultrasound performed by the on-call radiologist reports 'normal intratesticular arterial flow with a small reactive hydrocele; appearances favour epididymo-orchitis'. Urinalysis is negative for nitrites and leucocytes. The boy's parents ask whether surgery is really necessary and the registrar suggests admitting him for intravenous antibiotics and re-scanning in the morning.
1. Do you explore, and how do you reason about the Doppler result?
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Yes, he goes to theatre for scrotal exploration. The diagnosis of testicular torsion is clinical, and a Doppler report of preserved intratesticular flow does not exclude it. Flow can be present with intermittent torsion, with incomplete cord twisting, with collateral vessels, or because of technical factors and a small paediatric testis; the radiologist's report also anchors on a common alternative diagnosis when the history is not fully weighted.
The history is strongly suggestive: sudden onset, pain waking him from sleep, vomiting, a high horizontal testis and an absent cremasteric reflex. Negative urinalysis argues against epididymo-orchitis, and there is no discharge or fever. At 30 hours, salvage is likely to be low, but viability cannot be predicted from the duration or the scan, and exploration is the only way to determine it. Delaying until morning to rescan adds hours and risks losing a testis that might still be viable, and misses the opportunity for contralateral fixation.
I would explain to the parents that ultrasound can be falsely reassuring and that the operation is diagnostic and therapeutic. Consent covers exploration, detorsion and fixation, possible orchidectomy, and later prosthesis discussion. Antibiotics are not a substitute for exploration.
2. Describe your intraoperative strategy, including the contralateral side and consent.
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I would use a scrotal approach through a median raphe or transverse incision, open the tunica vaginalis, deliver the testis and untwist the cord. The testis is then wrapped in a warm saline pack and observed for 10–15 minutes. Viability is judged on colour, bleeding from a small incision in the tunica albuginea, and tone. If viable, I fix it with three non-absorbable sutures between the tunica albuginea and dartos, avoiding the epididymis and vessels. If necrotic, I perform orchidectomy.
Regardless of the fate of the left testis, I fix the contralateral testis, because the bell-clapper anomaly that predisposes to torsion is bilateral in most cases. This is a separate, prophylactic procedure and must be covered in the consent discussion; parents sometimes assume only the painful side will be touched.
Consent should include exploration, detorsion, bilateral fixation, possible orchidectomy, wound infection, haematoma, chronic pain and the small risk of further torsion despite fixation. If orchidectomy is required, I explain that a prosthesis is usually deferred until adulthood and that the other testis usually provides sufficient hormone production. Sperm banking is not feasible in the emergency setting but should be discussed at follow-up, and the time of onset and the time to theatre must be documented accurately.
3. If the testis is necrotic, how do you counsel the family, and what follow-up is needed?
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The family should be told clearly and privately that the testis had twisted, that the blood supply had been cut off for 30 hours and that it could not be saved. This is not their fault, and delay in presentation is common. I explain that the other testis has been fixed to prevent the same thing happening, that testosterone production is usually normal with one testis, and that fertility is usually preserved, though semen analysis can be offered in late adolescence if there is concern.
Cosmesis is a real issue for a 16-year-old. A testicular prosthesis is an option but is generally deferred until the scrotum has healed and he is old enough to make the decision, often at 18; I would document that this was discussed and arrange a follow-up appointment to revisit it. He should be warned about the small risk of recurrence despite fixation, chronic scrotal pain and the possibility of atrophy of a salvaged testis.
Follow-up at 6 weeks allows wound review, discussion of prosthesis, and assessment for atrophy if the testis was salvaged. I would also audit the pathway: the ultrasound report and the suggestion to delay exploration are a systems issue, and the case should be reviewed so that future suspected torsions are explored without waiting for imaging. Documentation of the counselling protects both the family and the clinical team.