Management of Acute Onset Scrotal Pain in a Teenager

In Episode 48 of Med School Question of the Week for USMLE, Faustine Ramirez, MedSchoolCoach expert tutor, answers this medical school question: A 16-year-old boy is brought to the emergency department with severe right scrotal pain that started 2 hours ago, after finishing football practice. He also complains of mild abdominal pain and nausea, but denies vomiting, diarrhea, constipation, chest pain, shortness of breath, or pain with urination. He is sexually active and uses condoms inconsistently. He has no past medical history and takes no medications. Upon arrival his temperature is 37.2 C, heart rate is 86/min, respiratory rate is 16/min, and blood pressure is 122/75. Examination reveals a swollen and exquisitely tender high riding right testis, in a transverse lie. Elevation of the right testis worsens his pain. The right testis does not move when the upper medial thigh is lightly touched. After performing doppler ultrasonography and urine studies, what is the next best step in management?

• Empiric ceftriaxone and azithromycin
• Empiric ciprofloxacin
• Empiric penicillin and trimethoprim-sulfamethoxazole
• Analgesia and catheterization
• Routine manual detorsion
• Urgent surgical detorsion and ipsilateral orchiopexy
• Urgent surgical detorsion and bilateral orchiopexy