A 14-year-old boy presents with acute scrotal pain after gym class. Which diagnosis is most likely?

A 14-year-old boy presents with acute scrotal pain after gym class. Which diagnosis is most likely?

• A. Epididymitis
• B. Hydrocele
• C. Testicular torsion
• D. Varicocele

Answer: (C)

Acute, unilateral testicular pain in a teenage boy after activity is classic for testicular torsion, a condition in which the spermatic cord twists and cuts off blood flow to the testicle. This is a surgical emergency because salvaging the testis depends on acting quickly to restore blood supply. Key clues are the sudden onset during physical exertion, the patient’s age, and the exam finding that the affected testis often sits higher than normal and lies horizontally. The cremasteric reflex on the affected side is commonly absent. These signs point to torsion rather than other causes of scrotal pain. Imaging with Doppler ultrasound can help by showing reduced or absent blood flow to the testis, but if torsion is strongly suspected clinically, urgent surgical evaluation should not be delayed for imaging. In contrast, epididymitis usually has a slower onset, possibly with urinary symptoms, and hydrocele or varicocele present as painless swelling or a “bag of worms” feel rather than an abrupt, painful onset. So, the scenario fits testicular torsion because of the sudden, severe unilateral pain in an adolescent and the typical exam findings, highlighting the need for rapid surgical management.

Acute, unilateral testicular pain in a teenage boy after activity is classic for testicular torsion, a condition in which the spermatic cord twists and cuts off blood flow to the testicle. This is a surgical emergency because salvaging the testis depends on acting quickly to restore blood supply.

Key clues are the sudden onset during physical exertion, the patient’s age, and the exam finding that the affected testis often sits higher than normal and lies horizontally. The cremasteric reflex on the affected side is commonly absent. These signs point to torsion rather than other causes of scrotal pain.

Imaging with Doppler ultrasound can help by showing reduced or absent blood flow to the testis, but if torsion is strongly suspected clinically, urgent surgical evaluation should not be delayed for imaging. In contrast, epididymitis usually has a slower onset, possibly with urinary symptoms, and hydrocele or varicocele present as painless swelling or a “bag of worms” feel rather than an abrupt, painful onset.

So, the scenario fits testicular torsion because of the sudden, severe unilateral pain in an adolescent and the typical exam findings, highlighting the need for rapid surgical management.