A 16 year old boy presents to the ER of the children's hospital complaining of severe onset testicular pain of one hour duration. He played a game of soccer several hours ago, but there is no reported injury or trauma. He is experiencing nausea and vomiting. There is no fever, dysuria, or discharge. The patient is not sexually active. You examine the affected testis, which is asymmetric from the other side, and it appears to be attached to the inner lining of the scrotum higher than usual. He says it feels tender. The cremaster reflex is absent. A blood count shows leukocytosis. This boy needs immediate surgery.
Challenge: What is the diagnosis?
Related Questions:
1. What is the cremaster reflex?
*Note: I have been told that you should not say "acute scrotum" out loud.
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Testicular torsion
Cremasteric reflex: contraction of the cremaster muscle (drawing up the testes) in response to stroking the superior medial part of the thigh
The Acute Scrotum
This presentation is classic for testicular torsion, a surgical emergency. The long axis of the testis is oriented transversely instead of longitudinally secondary to shortening of the spermatic cord from the torsion. The cremaster reflex is usually absent. The cremaster reflex is assessed by stroking the inner thigh which causes elevation of the ipsilateral testis due to cremasteric contraction. It may not be present in all teenagers.
Source: UpToDate.
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