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Testicular Torsion

• Usually presents with tenderness, abnormal orientation, high-riding testis, absent cremasteric reflex
• TWIST Score: swelling (2pts), hardness (2pts), N/V (1pt), high riding testis (1pt), absent cremasteric (1pt) - if 0-2 pts, no US (low risk), if 3-4 pts, obtain US (intermediate risk), if 5-7 pts, detorse in OR (US not required, high risk)
• Time is testis: risk for orchiectomy increases with increased delay from symptom onset to surgery, almost always salvagable before 6hr, almost always dead after 24hr
• Intermittent torsion: high degree of suspicion based on symptoms, treat with bilateral orchiopexy
• Perinatal torsion: occurs extravaginally (fixation has not yet occurred), can consider immediate salvage vs observation

Other causes of scrotal pain

• Appendix Testis/Epididymis torsion: most common cause of scrotal pain in prepubertal children, blue dot sign rare, treat conservatively
• Epididymitis: may be infectious or other causes, usually slower onset than torsion, obtain RUS/VCUG if prepubertal with positive UCx, encourage normal voiding if chemical epididymitis
• Idiopathic edema: color doppler may show hypervascularity of scrotal wall (Fountain sign), consider antihistamines, usually spontaneously resolves
• Henoch-Schonlein purpura: scrotum involved in 2-38%, may require scrotal exploration if concern for testicular torsion