The acute scrotum at midnight: no ultrasound, a three-hour road, and a mother who wants to wait

Working diagnosis: left testicular torsion.

Supporting features: sudden onset, severe pain, vomiting (a vagal response), a high-lying horizontal testis, an absent cremasteric reflex and no urinary symptoms.

Against the alternatives

• Epididymo-orchitis: usually a more gradual onset, fever, dysuria or urethral discharge, and the testis lies in a normal position with a preserved cremasteric reflex; it is uncommon at 15 without sexual activity or a urinary abnormality. Even if it were possible, the cost of being wrong is a lost testis.
• Torsion of the appendix testis: localised tenderness at the upper pole with a "blue dot" sign, and a normally lying testis.
• Inguinal hernia or trauma: no groin swelling, no history of direct injury.

The single most important decision: transfer for immediate surgical exploration. Do not wait for imaging. Ultrasound is not available and, even where it is, a normal or equivocal Doppler does not exclude torsion; a false-negative scan costs the testis. The mother must be told plainly that the testis is at risk of dying within hours and that the surgeon can do a scan if needed.

Now (next 20 minutes)

• Keep him nil by mouth.
• Analgesia: intravenous morphine titrated (0.1 mg/kg = about 6 mg, with an antiemetic), or pethidine if morphine is unavailable. Adequate analgesia does not mask the diagnosis and makes transfer humane.
• Intravenous access with 0.9% saline running slowly; correct any dehydration from vomiting.
• Take temperature, urine dipstick and observations; document the time of onset of pain and the time of your assessment explicitly.
• Telephone the receiving surgeon or the theatre coordinator directly - not just the ambulance - and state: "15-year-old, 5 hours of left torsion, absent cremasteric reflex, needs exploration on arrival."
• Consent: the mother signs for transfer and for surgery; document that the risks of delay were explained, and get her signature on that explanation.

Do not

• Do not give antibiotics - there is no evidence of infection, and they create false reassurance and delay.
• Do not attempt repeated manual detorsion as a substitute for surgery; if it is attempted at all it must not delay departure, and it does not remove the need for fixation.
• Do not send him alone or unescorted, and do not accept "come back in the morning".

Referral note

• Times (onset 18:00, assessed 23:00, departing 23:20), findings, analgesia given, allergies, weight, guardian contact.
• Request: exploration with bilateral orchidopexy or orchidectomy and contralateral fixation as appropriate.

Be honest, specific and non-committal about the outcome.

• "The testis has been twisted for about 5 hours. Most testes can be saved if they are untwisted within about 6 hours; the chance falls steeply after that and is low after 12–24 hours. We cannot know until the surgeon looks at it."
• "If it has already died, it will be removed, because leaving it can cause infection and damage to the other side. Removing it does not mean he cannot father children - one healthy testis is normally enough."
• "The surgeon will also fix the other testis to the scrotum, because the tendency to twist is usually present on both sides and we want to protect the good one."
• Mention that some boys have intermittent twisting beforehand, that nothing he did caused it, and that the priority is not to lose more time.

Reasoning behind the phrasing: the family is deciding whether to accept a 3-hour journey. Over-reassuring them risks the testis; over-promising a good outcome risks a complaint or a sense of betrayal later. Give a probability range, state clearly what is unknown, and keep the discussion focused on the decision they must make in the next 20 minutes.