A 19-year-old man presents with severe pain in his right testicle that woke him from sleep. He feels nauseous and has vomited twice whilst in the waiting room. When you examine him, his right testicle is extremely tender and he has abdominal tenderness in the right lower quadrant.

  1. What is the most likely diagnosis?
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This is a history that would be consistent with testicular torsion. This occurs when the spermatic cord twists, causing ischaemia. It is a surgical emergency and, with prompt action, the testis can often be saved. The peak age at which is occurs is 15-30 years of age.

History points that would favour testicular torsion as the diagnosis include:

  • Sudden onset
  • Severe pain
  • Accompanied by vomiting
  • Occurred during sleep (half of torsions occur during sleep)
  • Previous history of torsion to other testis
  • Previous history of less severe episodes that have resolved in recent past
  • History of undescended testis

Examination points that would favour testicular torsion as the diagnosis include:

  • Testis lies high in scrotum
  • Testis too tender to touch
  • Opposite testis lies horizontally (Angell’s sign)
  • Absence of cremasteric reflex
  1. What is Prehn’s sign and how is it relevant to this case?
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Prehn’s sign is performed by lifting the affected testicle. This will relieve the pain of epididymitis but not the pain caused by testicular torsion. A negative Prehn’s sign is suggestive of testicular torsion.

  1. How should this patient be managed?
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Testicular torsion is a surgical emergency that requires urgent assessment and immediate intervention to restore the flow of blood. Irreversible ischaemia begins around six hours after onset and this patient should be treated without delay.

It is sometimes possible to reduce the torsion manually by rotating the testis outwards. Success is defined as immediate relief of all symptoms and normal findings on physical examination. Most cases will require surgical however, and bilateral orchiopexy is required in all cases, and this should be performed immediately after de-torsion.

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