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Suspected testicular torsion — MRCEM SBA MCQ

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HardPaediatric emergenciesSuspected testicular torsionMRCEM SBA

A 14-year-old boy presents three hours after sudden onset of severe left testicular pain and vomiting. The pain briefly eased before becoming severe again. His left testis is high-riding with a transverse lie, and the left cremasteric reflex is absent. Urine dipstick is positive for leucocytes. A Doppler ultrasound performed before your assessment reports symmetrical intratesticular arterial flow. He has received analgesia. The hospital has an emergency theatre and a surgical and anaesthetic team able to operate on children. What is the most appropriate management plan now?

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Correct answer: A — Keep him nil by mouth and arrange immediate local surgical assessment for exploration.

The abrupt pain, vomiting, high-riding transverse testis and absent cremasteric reflex make testicular torsion strongly suspected. Brief improvement followed by recurrent pain raises the possibility of intermittent twisting and untwisting. Neither leucocytes on urine dipstick nor preserved arterial flow excludes torsion; Doppler can be falsely reassuring, particularly with early, partial or intermittent torsion. He needs immediate senior surgical assessment with a view to exploration, while being kept nil by mouth. Surgery should not be delayed to repeat imaging, and local exploration is appropriate because a suitable team and theatre are available. ([england.nhs.uk](https://www.england.nhs.uk/mids-east/wp-content/uploads/sites/7/2018/03/torsion-commissioning-guide.pdf)) **B** mistakes a potentially false-negative scan for a reason to delay referral. **C** gives undue weight to the urine dipstick: epididymitis would be more persuasive with a gradual onset and urinary symptoms, not these findings. **D** risks losing salvageable time through observation despite strong clinical suspicion. **E** adds a potentially harmful transfer when safe local surgery is available; transfer is reserved for circumstances in which appropriate local operative care cannot be provided. ([england.nhs.uk](https://www.england.nhs.uk/mids-east/wp-content/uploads/sites/7/2018/03/torsion-commissioning-guide.pdf))

Reference: Commissioning guide: Management of Paediatric Torsion (October 2016) — https://www.england.nhs.uk/mids-east/wp-content/uploads/sites/7/2018/03/torsion-commissioning-guide.pdf Boys and Young Men Presenting as a Urological Emergency with Unilateral Scrotal Pain Clinical Guideline (October 2024) — https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Urology/BoysandYoungMenpresentingasaUrologicalEmergencywithUnilateralScrotalPainClinicalGuidelines.pdf East of England ODN regional guideline: Children presenting with acute scrotum (9 May 2023) — https://eoeneonatalpccsicnetwork.nhs.uk/wp-content/uploads/2023/08/Children-Presenting-with-Acute-Scrotum.pdf