Testicular torsion — acute scrotal pain
PLAB 2 & PRES 3 · surgery · hard · 8 minutes
Candidate brief
You are an FY2 doctor/SHO in the Emergency Department. Mr Adam Collins, 18, presents with sudden severe left-sided scrotal pain and vomiting that began approximately 4 hours ago. Assess him urgently, explain the likely diagnosis and initiate an appropriate emergency management and escalation plan. Verbalise any examinations, investigations and immediate treatment you would undertake.
What examiners look for
Testicular torsion is twisting of the spermatic cord, which interrupts blood flow to the testicle. It is a time-critical surgical emergency. Suspect torsion in anyone with sudden severe unilateral scrotal or lower-abdominal pain, particularly when accompanied by nausea, vomiting or swelling. Previous brief episodes that resolved spontaneously may represent intermittent torsion and detorsion. Features supporting torsion include: Sudden severe pain. Nausea or vomiting. A swollen, firm or very tender testicle. A high-riding or horizontal testicular lie. An absent cremasteric reflex. No individual sign or clinical score safely excludes torsion. Prehn’s sign is unreliable. Examine with consent, privacy and a chaperone. Compare both testes and assess the abdomen and groins. Contact the senior surgical or urology team immediately. Provide analgesia, antiemetic treatment, IV access and keep the patient nil by mouth. Do not delay urgent surgery for ultrasound, blood tests, urine testing or completion of a fasting period when clinical suspicion is high. Scrotal exploration is both diagnostic and therapeutic. The testicle is untwisted and assessed for recovery. If viable, the affected testicle is fixed and the other testicle is normally fixed to prevent future torsion. If the affected testicle is non-viable, it may require removal. One healthy testicle is usually sufficient for testosterone production and fertility, but individual fertility outcomes cannot be guaranteed. Even successful manual detorsion does not remove the need for urgent surgical exploration and fixation.
Guideline references
- https://cks.nice.org.uk/topics/scrotal-pain-swelling/
- https://cks.nice.org.uk/topics/scrotal-pain-swelling/diagnosis/assessment/
- https://cks.nice.org.uk/topics/scrotal-pain-swelling/management/testicular-torsion/
- https://uroweb.org/guidelines/paediatric-urology/chapter/acute-scrotum
- https://www.baus.org.uk/trainees/testicular_torsion.aspx
- https://www.baus.org.uk/patients/information_leaflets/136/exploration_for_suspected_torsion_of_the_testis
- https://www.nhs.uk/symptoms/testicle-pain/
- https://www.guysandstthomas.nhs.uk/health-information/testicular-torsion-surgery
- https://www.cuh.nhs.uk/patient-information/testicular-torsion-information-for-teenagers/
- https://www.rcsi.com/surgery/-/media/feature/media/download-document/surgery/practice/ncp/general-paediatric-surgery-a-model-of-care-for-ireland-2024.pdf
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