🫀 Acute Scrotal Pain · Testicular Torsion · Epididymitis · Torsion of Appendix Testis · Orchitis

Schwartz Clinical Handbook — Chapter 67 · Testicular torsion (surgical emergency) · Appendix testis torsion (blue‑dot sign) · Epididymitis (cremasteric reflex intact) · Doppler ultrasound

Select onset (sudden vs gradual), nausea/vomiting, cremasteric reflex (present/absent), testicular lie (horizontal), blue‑dot sign (upper pole), urinary symptoms, fever, and Doppler flow → differentiate testicular torsion (urgent surgery) from torsion of appendix testis and epididymitis.
⚠️ Red flags: sudden pain, absent cremasteric reflex, horizontal testis → testicular torsion, Doppler stat, surgical exploration.

📋 Step 1 — Onset, exam & lab clues
📌 Diagnostic impressions
📖 Schwartz Ch 67

Select onset (sudden vs hours), nausea/vomiting, cremasteric reflex (absent highly suggests torsion), testicular lie (horizontal), blue‑dot sign (torsion of appendix testis), fever, dysuria, and Doppler ultrasound flow → differentiate testicular torsion (surgical emergency, absent flow) from torsion of appendix testis (blue dot, normal flow) and epididymitis (increased flow, pyuria).

✔️ Testicular torsion: sudden pain, absent cremasteric reflex, horizontal testis, nausea/vomiting.
✔️ Appendix testis torsion: gradual onset, blue‑dot sign, cremasteric present.
✔️ Epididymitis: gradual, pyuria, intact cremasteric, often >12‑14y.
📘 Schwartz pearls (Chapter 67)
• Testicular torsion: surgical exploration within 6h for salvage.
• Absent cremasteric reflex 92% sensitive, 94% specific for torsion.
• Doppler ultrasound: flow absent or decreased (torsion), increased (epididymitis).
• Manual detorsion (“open book” lateral to medial) can be attempted.
• Torsion of appendix testis: conservative (NSAIDs), resolves in 7‑10 days.