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Suspected testicular torsion — MSRA MCQ

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HardUrologySuspected testicular torsionMSRA

A 23-year-old man attends general practice with 4 hours of sudden severe left scrotal pain that began while sitting at work. He has vomited twice and describes lower abdominal pain. For the preceding 2 days he has had mild dysuria and a scant urethral discharge after unprotected sex with a new partner. He is afebrile and haemodynamically stable. Urine dipstick is positive for leucocytes but negative for nitrites. Examination shows a tender, swollen left hemiscrotum; the left testis lies high and horizontally, and the ipsilateral cremasteric reflex is absent. The local emergency department can provide scrotal Doppler ultrasonography in approximately 90 minutes. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Arrange emergency transfer for immediate on-call urological assessment for suspected torsion, without awaiting Doppler ultrasonography or microbiology results

Explanation lettering: E = shown as A · D = shown as B · B = shown as C · C = shown as D · A = shown as E

This presentation must be managed as testicular torsion. Although dysuria, urethral discharge and leucocyturia make sexually transmitted epididymo-orchitis plausible, they do not safely exclude torsion. The decisive features are sudden onset of severe unilateral pain over hours, vomiting/lower abdominal pain, a high horizontal testis and absent cremasteric reflex. Torsion is time-critical, with testicular salvage declining rapidly after about 6 hours; urgent urological assessment must therefore take priority over diagnostic testing or antimicrobial treatment. A and C are attractive because the sexual history and urethral symptoms support epididymo-orchitis, but treating this presumptively risks an avoidable delay to exploration. B is inappropriate because Doppler imaging should not delay emergency referral when torsion is suspected clinically. E incorrectly treats pyuria and stable observations as reassurance; urinary symptoms can coexist with, or distract from, torsion. NAAT and urine culture can be obtained during subsequent assessment, but must not determine the immediate pathway.

Reference: Scrotal conditions — NHS Greater Glasgow and Clyde Primary Care (Last reviewed 1 April 2026) — https://www.rightdecisions.scot.nhs.uk/ggc-primary-care/urology/scrotal-conditions/ Ultrasound scan referral guidelines — NHS Highland (Last reviewed 31 August 2023; next review due 31 August 2026) — https://www.rightdecisions.scot.nhs.uk/tam-treatments-and-medicines-nhs-highland/adult-therapeutic-guidelines/radiology/ultrasound-scan-uss-referral-guidelines-guidelines/