SU30.1-6 | Penis, Testis and Scrotum — Assignment

CLINICAL SCENARIO

A 17-year-old boy is brought to the emergency department at 11 p.m. by his father with sudden, severe pain in the left side of the scrotum that woke him from sleep about 5 hours ago. He has vomited once and cannot get comfortable. There is no history of trauma, no urinary symptoms and no fever. On examination he is in obvious distress; the left testis is swollen, exquisitely tender and appears to lie higher than the right with a horizontal lie. The cremasteric reflex cannot be elicited on the left, and lifting the testis does not relieve the pain. The right testis is normal.

1. The acute scrotum — differential and red flags

List the differential diagnosis of the acute scrotum in an adolescent and state which diagnosis you must exclude first and why. Identify the specific findings in this boy that point to testicular torsion.

Guidance: Contrast torsion, epididymo-orchitis, torsion of a testicular appendage and incarcerated hernia. Highlight 'must-not-miss' reasoning.

2. Distinguishing torsion from epididymo-orchitis

Construct a clear comparison of testicular torsion versus epididymo-orchitis, covering onset, age, fever/urinary symptoms, the cremasteric reflex, the effect of elevating the testis (Prehn sign) and testicular lie. Explain why these signs are helpful but never a substitute for surgical judgement.

Guidance: A table-style contrast in prose is acceptable. Emphasise that uncertainty is resolved in favour of exploration.

3. The role (and danger) of investigations

Discuss the role of Doppler ultrasound and urinalysis in the acute scrotum, and explain why imaging must NOT delay surgery when the clinical picture is torsion. State the salvage window and what determines testicular viability.

Guidance: Make the time-dependence explicit (ideally explore within ~6 hours). State that a negative/equivocal scan does not exclude torsion.

4. Definitive management

Describe the principles of operative management for confirmed torsion, including the assessment of viability, the action taken on the affected testis depending on viability, and why the contralateral testis is also addressed (bilateral fixation). Outline what you would do if the diagnosis turned out to be epididymo-orchitis instead.

Guidance: Keep to principles: detorsion, viability assessment, orchidopexy vs orchidectomy, and fixation of the other side. For epididymo-orchitis, note antibiotics and supportive care.

5. Communication, consent and aftercare

Explain how you would obtain urgent consent (including the possibility of orchidectomy and bilateral fixation) and communicate with the boy and his father under time pressure, and outline the aftercare and counselling, including the implications for fertility and future self-examination.

Guidance: Demonstrate consent for a possible loss of the testis and the rationale for fixing the healthy side.