Is the conservative management of the acute scrotum justified on clinical grounds?

To determine whether there is justification for a policy of conservative management of acute scrotal emergencies, based on the ability to exclude a twisted testicle or the assumption that there is a "missed torsion' when the duration of symptoms is prolonged.

The case notes of 209 consecutive emergency scrotal explorations, carried out in one district general hospital over a 7-year period, were reviewed. The decision to operate was based solely on a clinical diagnosis, with no information from additional radiological investigations.

The commonest finding was testicular torsion (39.5%) with an orchidectomy rate of 22%. Only 5% of scrotal torsions occurred in patients < 12 years of age, whereas 26% occurred in those > 20 years of age. In five of 82 cases (6%) of confirmed testicular torsion, the surgeon did not consider this the most likely diagnosis. With a pain duration of < 16 h, 89% of testes were salvaged, but with pain for > 16 h this decreased to 25%. In three cases the testis was viable after pain had been present for > 24 h.

In the absence of supportive radiological investigations, a small but significant number of twisted testes will be missed if conservative management is adopted.