Advanced Cases and Content: Genital Pain

11-year-old boy previously health who presents with testicular pain. He had sudden onset of pain that started 6 hours ago. He rates it 8/10, states it has been constant since then and is non-radiating. He denies dysuria and similar pain in the past. He further denies testicular trauma and recent fevers. He had one episode of emesis while in the waiting room.

Vitals: 130/84, HR 117, Temp 98 F, RR 30, 99% O2

GU: Asymmetric lie of testicles. Right higher than left, in a horizontal position, tender knot superior to the testicle and diffusely tender at testicle. Absent cremasteric reflex on right, present on left

Differential: Testicular torsion vs appendix torsion vs epididymitis



Patient’s ultrasound was concerning for absence of arterial and venous flow consistent with testicular torsion. Patient was accepted by Pediatric Urology at an outside facility with plans to go to the operating room.

Key Learning Points

  1. Testicular torsion may occur in children especially around puberty as there is increased testicular volume.
  2. Torsion occurs more common in the winter months as the cold causes cremasteric muscles contraction.
  3. Physical exam is more reliable than history for testicular torsion. Though preceding trauma may make it less likely for torsion to be a diagnosis, 10% of testicular torsion involve trauma.
  4. On physical exam, an absent cremasteric reflex highly supports a diagnosis of testicular torsion, however, its presence does not exclude the diagnosis. A horizontal lie further supports the diagnosis. A mass/knot superior to the testicle is likely the rotated spermatic cord and makes torsion likely.
  5. Although, viability of the testicles is greatest within the first 6 hours, it can still be salvaged up to 24 hours after. Be vigilant and get Urology on board ASAP.
  6. Attempt manual detorsion if it will take more than 2 hours to get the patient to the operating room.
  7. In 2/3 of the cases, you can detorse by rotating the testes outward to the thigh. In 1/3 of the cases, you have to rotate inward. Patients have immediate improvement in pain. You can further confirm with a bedside ultrasound.
  8.  Surgery is still required even after successful detorsion for confirmation of detorsion and orchiopexy.
  9. Ultrasound has variable sensitivity, but is highly specific. It may be falsely negative in cases of intermittent torsion or in early torsion.
  10. A heterogeneous echo parenchymal texture may indicate late torsion and poor salvageability rate  


  • Kaye, J. D., Shapiro, E. Y., Levitt, S. B., Friedman, S. C., Gitlin, J., Freyle, J., & Palmer, L. S. (2008). Parenchymal echo texture predicts testicular salvage after torsion: potential impact on the need for emergent exploration. The Journal of urology180(4S), 1733-1736.
  • Marx, J., Walls, R., & Hockberger, R. (2013). Rosen's emergency medicine-concepts and clinical practice e-book. Elsevier Health Sciences.
  • Tintinalli, J. (2015). Tintinallis emergency medicine A comprehensive study guide. McGraw-Hill Education.