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Case 358


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A 26-year-old male patient, with neither comorbidities nor use of medicines, seeks for urgency health service complaining of severe left inguinal pain radiating to the ipsilateral testicular region, which had started approximately one hour before. Physical examination demonstrated that the left testicle was painful, elevated and horizontalized over its longest axis. Prehn’s sign was negative and left cremasteric reflex was absent. Clinical diagnosis of testicular torsion was made and manual detorsion was attempted, with partial relief of pain. Scrotal scintigraphy was requested (images 1 and 2).

Considering the clinical history and scintigraphy imaging findings, what is the most appropriate approach?

a) Further investigation with complementary exams.


b) Elective procedure of scrotal fixation.


c) Hospital discharge.


d) Immediate bilateral orchiopexy.


Image 1 - Analysis: Dynamic sequential imaging of the blood flow acquired immediately after intravenous administration of the radiopharmaceutical (99mTc-PYP), demonstrating barely absent blood flow through the left testicle, which outlines subtle sign of blood flow stop adjacent to the left testicle.


Image 2 - Analysis: Static imaging in blood pool phase, demonstrating cold spot in the left testicle area (red arrow), which corresponds to severe hypoperfusion when compared to the normal contralateral testicle (blue arrow), associated to a subtle enhancing halo compatible with missed testicle.


-        The clinical presentation of testicular torsion includes sudden onset of severe scrotal pain, with or without radiation to the lower abdomen. 

-        Other characteristic clinical signs: increased sensitivity, hyperemia and scrotal swelling; horizontalization of testis, absent cremasteric reflex and ipsilateral negative Prehn’s sign.

-        It is considered urological emergency and treatment must be initiated within the first hour of symptoms onset in order to ensure testicular viability.

-        The surgical approach is bilateral orchiopexy in those cases that do not respond to the manual detorsion of the spermatic cord, as long as infectious causes are ruled out (orchiepididymitis) 

-        Further complementary exams are indicated in those cases with no etiological diagnosis, provided that evaluation is available and quickly feasible.

-        Ultrasonography is more readily available and does not utilize ionizing radiation; meanwhile, scrotal scintigraphy is more sensitive, but less available and relies on ionizing radiation.


 - Lima DX, Câmara FdP, Fonseca CEC. Urologia: Bases do Diagnóstico e Tratamento. São Paulo: Atheneus; 2014. 248 p

- Eyre RC, O'leary MP, Kunins L. Evaluation of acute scrotal pain in adults [internet]. 2018. [Accessed in: september, 2018]. Available in:

- Ogunyemi OI. Testicular Torsion Workup [internet]. [Accessed in: november, 2018]. Available in:


Vinícius Rezende Avelar, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: vireavelar[at]


Daniel Xavier Lima, Urologist and Adjunct Professor of the Department of Surgery at Medical School of Universidade Federal de Minas Gerais. 

E-mail: contato[at]


Álvaro Luiz Barroso, Head of the Department of Nuclear Medicine at Hospital Biocor/Belo Horizonte – MG.

E-mail: alvarobarroso[at]


Rogério Augusto Pinto Silva, Sonographer at Hospital das Clínicas da UFMG.

E-mail: rapsilva[arroba]


Rafael Valério, Amanda Lauar, Mateus Nardelli, Luana Almeida, professor José Nelson Mendes Vieira; professor Viviane Santuari Parisotto Marino

Translated by

Ana Luísa Melgaço Almeida, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: analuisamelgaco[at]

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