Acute Scrotum
The acute scrotum is a time-critical triage: the only question that matters first is 'is this testicular torsion?' — because the testis dies within hours.
The big picture
Three diagnoses cause most acute scrotums: testicular torsion (a surgical emergency), epididymo-orchitis (usually medical), and torsion of a testicular appendage (self-limiting). Your whole job in the first minutes is to separate the emergency from the rest, because torsion has a clock.
Torsion is a clinical diagnosis with a 6-hour window — when in doubt, explore. A normal ultrasound does not exclude torsion.
Red flags
Peak torsion age; do not wait for imaging in a classic presentation.
Bell-clapper anatomy lets the testis twist — explore.
Highly suggestive of torsion (though not perfectly sensitive).
Visceral pain pattern of torsion — treat as emergency.
Mechanism pathway
Tap any step to see why it happens.
Diagnostic algorithm
Each step answers one question. Tap to expand.
Treatment ladder
Save the testis: in any plausible torsion, explore without delay; treat the alternatives medically once torsion is excluded.
Complications
- Testicular loss from delayed torsion
- Abscess from untreated epididymo-orchitis
- Infertility/atrophy after ischaemia
- Orchidectomy for non-viable testis
- Recurrence if orchidopexy not performed
- Explore early in any plausible torsion
- Always fix the contralateral testis (shared bell-clapper anatomy)
- Necrotic testis: orchidectomy + contralateral orchidopexy
- Abscess: drainage + antibiotics
Memory hooks
Acute scrotum = torsion until proven otherwise.
6-hour window — explore.
Prehn relieves epididymitis, not torsion.
Blue dot = torted appendage.
Fix both sides.
Board traps
Teenager, sudden pain, absent cremasteric reflex — explore, do not scan-and-wait.
Normal Doppler ultrasound — does not rule out torsion.
Prehn's positive (relief on elevation) suggests epididymitis but never excludes torsion.
Viable testis detorsed but contralateral side not fixed — recurrence risk.
Clinical cases
A 14-year-old has 3 hours of sudden severe left scrotal pain and vomiting. The left testis is high-riding with absent cremasteric reflex. The on-call team suggests waiting for a morning ultrasound.
What is the correct management?