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may be referred to the abdomen, genitalia should be examined carefully in every
child who complains of abdominal pain. Urinalysis is usually negative.
The diagnosis of testicular torsion is made clinically when unilateral, acute
scrotal pain presents with testicular changes, absent cremasteric reflex, and
associated nausea or vomiting. Immediate surgical consultation for exploration
and repair, without delay for imaging, is optimal. A clinical scoring system
(ranging from 0 to 7) that takes into account the presence of nausea or vomiting
(1 point), testicular swelling (2 points), hard testis on palpation (2 points), highriding testis (1 point), and absent cremasteric reflex (1 point) has been derived
and validated. In multiple studies, a high-risk score of 7 accurately identifies
testicular torsion with 100% specificity and 100% positive predictive value for
torsion. Use of a validated risk-scoring system should be incorporated into a
workflow to obtain prompt urological consultation and expediate surgical
management of testicular torsion.
Color Doppler ultrasound evaluates the size, shape, echogenicity, and perfusion
of the testes and associated structures, and confirms the absence of torsion. In
testicular torsion there is decreased or absent arterial blood flow within the
affected testicle ( Fig. 61.4 ). With high sensitivity (88.9%) and specificity
(98.8%) and a low false-negative rate of 1%, ultrasound is the first-line imaging
modality. False-positive scans occur when testicular flow appears decreased due
to a large hydrocele, abscess, hematoma, or hernia. False-negative ultrasounds
occur from spontaneous detorsion, partial or intermittent torsion, or late torsion
when severe, overlying scrotal edema with increased vascularity obscures the
underlying ischemic testis. Limitations of Doppler sonography exist in small,
lower flow prepubertal testes and due to operator-dependent nature of this test.
Previously used nuclear perfusion scans are limited by associated time delay and
radiation exposure. Again, imaging should not delay surgical consultation or
treatment, as this can prolong testicular ischemia and may increase the likelihood
of testicular loss.