Clinical Presentation. The sudden onset of severe unilateral pain, often with nausea and vomiting, is the classic presentation of testicular torsion

The sudden onset of severe unilateral pain, often with nausea and vomiting, is the classic presentation of testicular torsion. The pain usually is unrelenting, but seemingly minimal pain may occur in patients who are very stoic or when the torsion has been longstanding. A history of previous bouts of intermittent testicular pain may be given and likely represents previous intermittent torsion and detorsion.

The physical examination should include an investigation of the abdomen, inguinal area, and scrotum. The abdomen and inguinal area should be inspected for other causes of scrotal pain, such as an inguinal hernia. Depending on the duration of the torsion, the scrotum can show various degrees of erythema and induration. If landmarks are still present, the involved testicle may be riding higher (the involved testicle is "high-riding", have a transverse orientation, or have the epididymis located anteriorly.

Neonates with unilateral cryptorchidism may have had an in utero torsion. Prenatal testicular torsion will present with an empty scrotum. Others may present with a red, firm, tender mass of the groin area which may not be distinguishable from an incarcerated hernia.

The cremasteric reflex frequently is absent in patients who have torsion, but presence of the cremasteric reflex certainly does not exclude torsion. The testicle usually is palpably tender when there is spermatic cord torsion, whereas the focal area of tenderness is in the superior testis or caput epididymis when the patient has a torsed appendix testis or epididymitis. In the later stages of testicular torsion, scrotal edema and erythema may obliterate these landmarks, making the examination more difficult.

Note! The cremasteric reflex - stimulation of the skin on the front and inner thigh (over Scarpa's triangle) retracts the testis on the same side. Stimulus usually causes cremasteric muscle contraction.

Interpretation

§ Normal: Cremasteric reflex present (Testicle rises)

Seen in Epididymitis

§ Abnormal: Cremasteric reflex absent (no Testicle rise)

Suggests Testicular Torsion

Also absent in 50% of boys under age 30 months (do not use this test under age 30 months!).

In boys, this reflex may be exaggerated which can occasionally lead to a misdiagnosis of cryptorchidism.

The cremasteric reflex can be helpful in recognizing testicular emergencies. The presence of the cremasteric reflex does not eliminate testicular torsion from a differential diagnosis, but it does broaden the possibilities to include epididymitis or other causes of scrotal and testicular pain.

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