A 19-year-old man comes to the emergency department due to intense scrotal pain over the past 6 hours. The pain started shortly after participating in a soccer game; he does not recall any specific trauma. The patient took ibuprofen at home with minimal relief. He is sexually active and has been treated twice in the past for Neisseria gonorrhoeae. Temperature is 36.9 C (98.5 F), blood pressure is 110/86 mm Hg, and pulse is 92/min. On examination, there is no inguinal adenopathy. There is significant discomfort with scrotal examination primarily on the right where a high-riding swollen mass is palpated within the hemiscrotum. The left testicle is palpated lower in the scrotum. Which of the following additional physical examination findings is most likely present in this patient?
Testicular torsion | |
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This patient has acute, severe, progressive scrotal pain with a high-riding scrotal mass, findings concerning for testicular torsion. Torsion is caused by twisting of the spermatic cord and its contents, leading to venous congestion, ischemia, and necrosis of the testis if untreated.
Classic presentation is an adolescent or young adult male with sudden onset of unilateral scrotal pain, usually with associated nausea and vomiting. Poor testicular perfusion can also cause reactive scrotal edema and discoloration (eg, erythema) on examination. Because the cremaster muscle lies within the spermatic cord, an absent cremasteric reflex (testicular elevation when stroking the ipsilateral inner thigh) is highly suggestive of testicular torsion. The testicle itself is often transverse (due to inadequate fixation of the lower pole of the testis to the tunica vaginalis) and high riding (due to cord shortening with rotation).
Diagnosis can be clinical with classic findings or may require ultrasound evaluation. Twisting of the spermatic cord and/or decreased testicular perfusion on ultrasound confirms the diagnosis.
(Choice B) Increased abdominal pressure (eg, cough, Valsalva maneuver) can lead to bulging within the groin or scrotum due to an inguinal hernia. If incarcerated, a hernia can lead to acute scrotal pain, but a high-riding testicle would not be expected.
(Choice C) Varicocele, which is characterized by a scrotal mass with a "bag of worms" texture, increases in size when standing as compared with supine positioning. This dilation of the pampiniform plexus may cause a dull ache, but not acute, severe pain.
(Choice D) Epididymitis caused by infection (eg, Neisseria gonorrhoeae) or trauma causes acute scrotal pain that is relieved with manual elevation of the testicle. In contrast to this case, urinary symptoms (eg, dysuria, frequency, urgency) are typical, and a high-riding testicle would not be seen.
(Choice E) Hydrocele is a fluid collection within the tunica vaginalis that transilluminates on examination and causes scrotal enlargement but not acute pain.
Educational objective:
Testicular torsion presents with acute, severe, progressive unilateral scrotal pain. Classic examination findings include scrotal edema and discoloration, a high-riding testicle, and an absent cremasteric reflex (ie, absence of testicular elevation when stroking the ipsilateral thigh).