Introduction

Learning objectives

Recognize testicular torsion as the diagnosis that must never be missed.
Identify the clinical findings that increase suspicion of torsion.
Understand why Doppler ultrasound should not delay referral when clinical suspicion is high.

Video lesson

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Summary

The diagnosis we must never miss is testicular torsion.

Torsion compromises blood flow to the testicle and is a time-dependent surgical emergency.

Suspect it when there is

sudden severe pain;
nausea or vomiting;
high-riding testicle;
abnormal position;
scrotal edema;
absent cremasteric reflex, although no single sign can exclude it.

⚠️ Immediate referral

With high clinical suspicion: urgent surgical/urologic referral.

Doppler ultrasound can be useful when there is doubt, but it should not delay exploration when clinical suspicion is high.

Key concept

Acute testicular pain → first ask yourself: "Could this be torsion?"

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Practical algorithm

🔴 Urgent referral / emergency

Sudden testicular pain → rule out torsion.
Fever/sepsis + obstructed urinary tract → urgent urinary drainage.
Acute urinary retention → bladder decompression; urgent referral if it cannot be resolved or if complications are present.
Hematuria + clot retention → urgent assessment and management.
Trauma + suspected urethral injury → avoid repeated blind catheterization attempts.

🟠 Priority referral

Solid testicular mass → rule out tumor.
Suspicious renal mass → characterization and urologic evaluation.
Gross hematuria → investigate the cause.
Persistently elevated PSA/suspicious DRE → prostate cancer risk assessment.

🟢 Scheduled referral depending on context

Recurrent UTI → look for a predisposing cause.
Erectile dysfunction → refer if complex, refractory, or with associated pathology.
Urinary incontinence → refer if complex, if warning signs are present, or if initial management fails.

The primary care physician does not need to resolve all urologic pathology. They must know how to perform an initial evaluation, recognize warning signs and, above all, distinguish which patient can wait from the one in whom a delay may compromise an organ, renal function, or even life.

Clinical case

Content pending upload Progressive clinical case focused on decision-making.

Self-assessment

Questions pending upload 5–10 multiple-choice questions on this lesson.

References

Links pending upload References to PubMed, DOI, scientific society guidelines and journals.

Acute testicular pain