Testicular torsion - Key points for the USMLE

Torsion is the most common cause of acute scrotal swelling and pain
-Underlying cause is a high attachment of tunica vaginalis that occurs in 12% of males
-Symptoms may include nausea and vomiting  and even fever (in addition to testicular symptoms)
-Examination may demonstrate a horizontal and elevated testis
-The cremasteric reflex is usually absent, but its presence does not rule out testicular torsion.
-Elevation of the scrotum does not relieve the pain 
-Doppler can confirm diagnosis although it is often not needed
-If surgery is done after 6 hours of onset the chances of testicular atrophy are extremely high
-During surgery the opposite (normal) testis is also fixed because the high attachment anomaly is often bilateral

Differential diagnosis:
1) Acute epididymitis and/or orchitis
-Onset is more gradual with fever and dysuria.
-Elevation of the scrotum may reduce discomfort
-Cremasteric reflex may or may not be present
-Teatment is with rest, analgesia, and antibiotics if there is concern about a bacterial infection

2) Torsion of the appendix testis
-Localized tenderness over the upper portion of the testis
-Blue dot sign
-Cremasteric reflex is present
-Treatment is analgesia