A 25-year-old man presents to the emergency department with a 4-hour history of sudden-onset severe left scrotal pain, nausea, and vomiting. On examination the left testis is high-riding and exquisitely tender; the cremasteric reflex is absent on the left. What is the immediate management?

• A Urgent Doppler ultrasound of the scrotum to confirm testicular torsion
• B Urgent surgical scrotal exploration and bilateral orchidopexy (or orchidectomy if non-viable) ✓
• C Urine culture and IV antibiotics for epididymo-orchitis
• D Manual detorsion of the testis and schedule elective orchidopexy

Explanation

Testicular torsion is a urological emergency — salvage rates approach 100% if detorsed within 6 hours but fall sharply thereafter (less than 10% after 24 hours). The diagnosis is clinical: high-riding testis, absent cremasteric reflex, and acute onset of pain. Imaging must not delay surgery. Immediate scrotal exploration is mandatory; the affected testis is detorsed and assessed for viability — orchidopexy if viable, orchidectomy if necrotic — and the contralateral testis is always fixed (bilateral orchidopexy) due to the 'bell-clapper' deformity being bilateral in 40–80% of cases. Doppler ultrasound may show absent flow but is not 100% sensitive and wastes critical time. Epididymo-orchitis is a diagnosis of exclusion and must not be assumed in young men without sexual history.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.