🩻 Imaging & Diagnostics Color Doppler ultrasound: decreased/absent flow in torsion, increased flow in epididymitis. If strongly suspect torsion → surgical exploration without imaging.
🧬 Chronic Conditions Varicocele (left-sided "bag of worms", worse standing, may affect fertility). Testicular tumor (painless hard mass). Hydrocele (transilluminates).
🚩 Red Flags Acute scrotal pain + absent cremasteric reflex + high-riding testis = torsion until proven otherwise. Neonatal torsion: extravaginal, usually nonviable; contralateral orchipexy recommended.
💡 Key Takeaway: Testicular torsion is a surgical emergency. If history and exam strongly suggest torsion, proceed to exploration without delay. Doppler ultrasound helpful if equivocal. Salvage rate ~100% if detorsion within 4-6 hours, falls to 20% at 8-12 hours.
🩺 Clinical Approach to Acute Scrotal Swelling: Algorithm
🔹 Step 1: Triage - is this a surgical emergency?
• Sudden onset severe pain + nausea/vomiting + absent cremasteric reflex → testicular torsion until proven otherwise. Immediate urology consult.
• Incarcerated hernia: inguinal mass, cannot reduce, vomiting → emergency reduction or surgery.
• Testicular rupture after trauma: ultrasound to assess tunica albuginea integrity.
🔹 Step 2: History key differentiators
• Onset: torsion = abrupt (seconds to minutes); epididymitis = gradual (hours to days); appendix torsion = progressive over 1-2 days.
• Associated symptoms: dysuria/urethral discharge suggests epididymitis. Previous similar episodes suggest intermittent torsion.
• Age: neonate → extravaginal torsion; 2-12y → appendix torsion most common; adolescent → torsion or epididymitis (STI).
🔹 Step 3: Physical examination pearls
• Cremasteric reflex: stroke inner thigh → testis retracts. Absent in torsion (sensitivity ~60-100%).
• Blue dot sign: tender nodule at upper pole of testis visible through skin → torsion of appendix testis.
• Position: high-riding, transverse lie suggests torsion.
• Transillumination: hydrocele glows; hernia/tumor may not.
🔹 Step 4: Imaging decision rule
• Strongly suspect torsion → go directly to surgery, no imaging.
• Equivocal or suspect epididymitis/appendix torsion → color Doppler ultrasound. Absent flow = torsion; increased flow = epididymitis; normal/increased flow with tender nodule = appendix torsion.
• Urinalysis/NAAT for STI in sexually active adolescents.
🔹 Step 5: Chronic scrotal swelling
• Varicocele: "bag of worms", left-sided >95%, worse standing/Valsalva, decompresses supine. Ultrasound if right-sided or prepubertal to rule out mass.
• Hydrocele: non-tender, transilluminates. Communicating: fluctuates in size. Noncommunicating: stable.
• Testicular tumor: painless hard mass → urgent ultrasound and tumor markers.