Conclusion

Next time you are faced with a patient with acute lower abdominal and/or scrotal pain, consider the diagnosis of testicular torsion regardless of age. Understand that the duration of symptoms should not guide urgency of management and that all cases of suspected testicular torsion must be treated as a surgical emergency. Remember that the presence of a cremasteric reflex does not rule out testicular torsion and that all clinical characteristics and even Doppler ultrasound have significant limitations in making or excluding the diagnosis. Urological consultation should always be obtained in equivocal cases.

Special thanks to Dr. Natalie Wolpert and Dr. Yonah Krakowsky for their expert contributions to the EM Cases podcast that inspired this article.

References

1. Davis JE, Silverman M. Scrotal emergencies. Emerg Med Clin North Am. 2011;29(3):469-484.
2. Howe AS, Vasudevan V, Kongnyuy M, et al. Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion. Transl Androl Urol. 2017;6(6):1159-1166.
3. Mellick LB, Sinex JE, Gibson RW, et al. A systematic review of testicle survival time after a torsion event. Pediatr Emerg Care. 2019;35(12):821-825.
4. Perrotti M, Badger W, Prader S, et al. Medical malpractice in urology, 1985 to 2004: 469 consecutive cases closed with indemnity payment. J Urol. 2006;176(5):2154-2157.
5. Mejdoub I, Fourati M, Rekik S, et al. Testicular torsion in older men: it must always be considered. Urol Case Rep. 2018;21:1-2.
6. Tang YH, Yeung VHW, Chu PSK, et al. A 55-year-old man with right testicular pain: too old for torsion? Urol Case Rep. 2017;11:74-75.
7. Farrington NL, Lucky MA, Barnes T, et al. Confirmed testicular torsion in a 67 year old. J Surg Case Rep. 2014;2014(1):rjt119.
8. Alqasem S, Alhamdan A, Alhefzi A, et al. Acute scrotum in elderly; is it torsion! Urol Case Rep. 2020;28:101032.
9. Mellick LB, Sinex J. Testicular torsion pain honeymoons. Pediatr Emerg Care. 2019;35(12):e241-e244.
10. Wang F, Mo Z. Clinical evaluation of testicular torsion presenting with acute abdominal pain in young males. Asian J Urol. 2019;6(4):368-372.
11. Ciftci AO, Senocak ME, Tanyel FC, et al. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 2004;14(5):333-338.
12. Mellick LB. Torsion of the testicle: it is time to stop tossing the dice. Pediatr Emerg Care. 2012;28(1):80-86.
13. Paul EM, Alvayay C, Palmer LS. How useful is the cremasteric reflex in diagnosing testicular torsion? [Supplement]. J Am Coll Surg. 2004;199(3):101.
14. Beni-Israel T, Goldman M, Bar Chaim S, et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. 2010; 28(7):786-789.
15. Roth B, Giannakis I, Ricklin ME, et al. An accurate diagnostic pathway helps to correctly distinguish between the possible causes of acute scrotum. Oman Med J. 2018;33(1):55-60.
16. Frohlich LC, Paydar-Darian N, Cilento Jr BG, et al. Prospective validation of clinical score for males presenting with an acute scrotum. Acad Emerg Med. 2017;24(12):1474-1482.
17. Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol. 2018;48(5):735-744.
18. McDowall J, Adam A, Gerber L, et al. The ultrasonographic “whirlpool sign” in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis. Emerg Radiol. 2018;25(3):281-292.