A 22-year-old man is brought to the emergency department because of progressive left-sided scrotal pain for 4 hours. He describes the pain as throbbing in nature and 6 out of 10 in intensity. He has vomited once on the way to the hospital. He has had pain during urination for the past 4 days. He has been sexually active with 2 female partners over the past year and uses condoms inconsistently. His father was diagnosed with testicular cancer at the age of 51 years. He appears anxious. His temperature is 36.9°C (98.42°F), pulse is 94/min, and blood pressure is 124/78 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Examination shows a tender, swollen left testicle and an erythematous left hemiscrotum. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs. Which of the following is the most appropriate next step in management?

CT scan of the abdomen and pelvis

Measurement of serum mumps IgG titer

Measurement of serum α-fetoprotein level

A 13-year-old boy is brought to the emergency department by his mother because of vomiting and severe testicular pain for 3 hours. The boy has had 4–5 episodes of vomiting during this period. He has never had a similar episode in the past and takes no medications. His father died of testicular cancer at the age of 50. His immunizations are up-to-date. He appears anxious and uncomfortable. His temperature is 37°C (98.6°F), pulse is 90/min, respirations are 14/min, and blood pressure is 100/60 mm Hg. Cardiopulmonary examination shows no abnormalities The abdomen is soft and nondistended. The left scrotum is firm, erythematous, and swollen. There is severe tenderness on palpation of the scrotum that persists on elevation of the testes. Stroking the inner side of the left thigh fails to elicit elevation of the scrotum. Which of the following is the most appropriate next step in management?

Surgical exploration of the scrotum

Ceftriaxone and doxycycline therapy

CT scan of the abdomen and pelvis

A 70-year-old man with metastatic castration-resistant prostate cancer presents to the emergency department with severe back pain, bilateral lower extremity weakness (3/5 strength), and urinary retention that started 8 hours ago. He has known bone metastases and his PSA has been rising despite androgen deprivation therapy. MRI spine shows an epidural mass at T10 with severe spinal cord compression and near-complete canal obliteration. He is neurologically intact above T10. Radiation oncology, neurosurgery, and medical oncology are consulted. Evaluate the optimal management approach.

Emergent surgical decompression followed by radiation therapy

Corticosteroids, radiation therapy, and switch to next-line systemic therapy

Stereotactic radiosurgery as single-modality treatment

Palliative care consultation and comfort measures only given metastatic disease

High-dose corticosteroids and emergent radiation therapy alone

A 3-year-old boy is brought to the clinic for evaluation of an undescended left testicle noted since birth. The right testicle is in normal scrotal position. On examination, the left testicle is palpable in the inguinal canal and can be manipulated to the upper scrotum but retracts immediately upon release. The testicle appears smaller than the contralateral side. The parents report they were told to wait and see if it descends spontaneously. What is the most appropriate management at this time?

Immediate orchiopexy given the patient's age

Reassurance and follow-up at age 5 years before school entry

Continue observation as the testicle is palpable and may still descend

Orchiectomy given the size discrepancy and malignancy risk

Hormonal therapy with hCG to stimulate testicular descent

A 58-year-old man with a 15-pack-year smoking history undergoes radical cystectomy with ileal conduit urinary diversion for muscle-invasive bladder cancer. Final pathology shows pT3N1 disease with 3 of 18 lymph nodes positive for metastatic urothelial carcinoma, with negative surgical margins. His postoperative recovery is uncomplicated. The oncology team recommends adjuvant chemotherapy, but the patient has baseline chronic kidney disease with creatinine 2.0 mg/dL and GFR 35 mL/min/1.73m². Evaluate the optimal management strategy.

Clinical trial enrollment or gemcitabine-based regimen with close monitoring

Immunotherapy with checkpoint inhibitor as adjuvant treatment

Standard cisplatin-based adjuvant chemotherapy despite renal function

Surveillance only given contraindication to effective chemotherapy

Carboplatin-based chemotherapy as substitute for cisplatin

A 65-year-old man with benign prostatic hyperplasia (BPH) presents with acute urinary retention. A Foley catheter is placed, draining 1200 mL of clear urine. Over the next 6 hours, he produces 800 mL/hour of urine and becomes hypotensive with BP 85/50 mmHg. Laboratory studies show sodium 148 mEq/L, potassium 3.2 mEq/L, and creatinine 2.1 mg/dL (baseline 1.0 mg/dL). What is the underlying pathophysiologic mechanism and appropriate management priority?

Post-obstructive diuresis with sodium and water loss; careful fluid replacement matching urine output

Acute tubular necrosis from obstruction; initiate dialysis preparation

Sepsis from urinary tract infection; broad-spectrum antibiotics and vasopressors

Prerenal azotemia from volume depletion; aggressive IV fluid resuscitation with normal saline

SIADH from bladder distension; fluid restriction

Testicular torsion emergency management for USMLE Step 3: High-Yield Surgery Lessons

🌪️ Core concept - Twist and Shout

Urologic Emergency: Twisting of the spermatic cord obstructs testicular blood flow, leading to ischemia and infarction.
Diagnosis: Primarily clinical (sudden severe pain, high-riding testis, absent cremasteric reflex).
Imaging: STAT color Doppler ultrasound confirms ↓ or absent blood flow.

⭐ "Time is testis": Salvage rate is >90% if detorsion occurs within 6 hours of symptom onset.

Management: Immediate surgical exploration, detorsion, and bilateral orchiopexy.
💡 Manual detorsion ("open the book" motion) can be attempted as a temporizing measure.

🏃‍♂️ The Sudden Scrotal Saga

Testicular Torsion: Anatomy & Symptoms

Onset: Acute, severe, unilateral testicular pain, often with nausea & vomiting.
Patient: Typically adolescents; may awaken patient from sleep.
Physical Exam:
- Swollen, erythematous, and exquisitely tender hemiscrotum.
- High-riding testis with a horizontal lie.
- ⚠️ Absent cremasteric reflex on the affected side.
- Negative Prehn's sign (scrotal elevation does NOT relieve pain).

⭐ The underlying "bell clapper" deformity allows the testis to rotate freely on the spermatic cord, as the tunica vaginalis attaches abnormally high.

⏱️ Diagnosis - Racing the Clock

Diagnosis is clinical and extremely time-sensitive.
Physical Exam:
- Absent cremasteric reflex (highly sensitive).
- High-riding, transversely oriented testis.
- Negative Prehn's sign (no pain relief with scrotal elevation).
Imaging: STAT Color Doppler Ultrasound is the test of choice.
- Key Finding: Absent or significantly ↓ arterial flow.
- Helps differentiate from epididymitis (hyperemia/↑ flow).
Urinalysis is usually normal.

⭐ A high index of suspicion warrants immediate urologic consultation and potential surgical exploration, even before imaging. Do not delay surgery for ultrasound if the diagnosis is clear.

Color Doppler ultrasound: Absent vs. normal testicular flow

⚕️ Management - The Untangling Act

This is a true urological emergency. Time is testis.

Immediate surgical consultation is mandatory.
⚠️ Salvage Rates: >90% if corrected <6 hours; <10% after 24 hours.
Manual Detorsion:
- Temporary measure while awaiting OR.
- 📌 Mnemonic: "Open the book" → rotate testis outwards (medial to lateral).

⭐ Bilateral Orchiopexy: The contralateral (unaffected) testis must also be fixed. The underlying anatomical cause (bell-clapper deformity) is frequently bilateral, and fixation prevents future torsion on the other side.

Surgical orchiopexy for testicular torsion

📉 Complications - Aftermath & Outlook

Testicular Infarction/Necrosis: Primary risk with delayed reperfusion (>6 hrs).
- Requires orchiectomy (surgical removal of non-viable testis).
Subfertility/Infertility:
- Due to loss of testicular mass.
- Potential for anti-sperm antibodies post-torsion.
Testicular Atrophy: Affected testis may shrink even if salvaged.
Contralateral Orchiopexy: Standard procedure to fix the unaffected testis, preventing future torsion.

⭐ Salvage rates are highly time-dependent: ~90% if surgery is within 6 hours, but drops to <10% after 24 hours.

⚡ Biggest Takeaways

Testicular torsion is a urologic emergency requiring immediate intervention to preserve testicular viability.

Suspect in any male with sudden, severe testicular pain, often with nausea and vomiting.

Key exam findings: high-riding testis, horizontal lie, and an absent cremasteric reflex.

Color Doppler ultrasound is the diagnostic test of choice, showing absent or decreased blood flow.

Immediate surgical exploration is the definitive management.

Testicular salvage rates drop sharply after 6 hours of ischemia.

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