Acute testicular pain and paraphimosis
Treat suspected torsion as time-critical and base infection treatment on clinical risk, not age alone.
Acute scrotal pain flowchart
- Suspected torsion: establish age firstThis determines the immediate local receiving service; do not delay simultaneous assessment, analgesia or escalation.
- Age 10 or under — Sheffield Children's HospitalSpeak to Sheffield Children’s Hospital immediately and follow the current time-critical transfer route.Age 11 or over — DRISpeak to the DRI on-call surgical/Urology team immediately and follow the emergency theatre pathway.
- Immediate actions for both age groupsRecord onset, provide analgesia, keep nil by mouth, examine both testes and calculate the TWIST score. The score supports—not replaces—clinical judgement.
- Torsion cannot be excluded?Sudden severe pain, abnormal lie/high testis, nausea/vomiting, absent cremasteric reflex or diagnostic uncertainty.
- Yes — immediate surgical/Urology reviewNil by mouth and prepare for urgent exploration. Do not delay for ultrasound when suspicion is high.No — assess alternativesEpididymo-orchitis, torsion of appendage, hernia, trauma, tumour or referred pain; investigate according to findings.
TWIST score
| Finding | Points |
|---|---|
| Testicular swelling | 2 |
| Hard testis | 2 |
| Absent cremasteric reflex | 1 |
| Nausea or vomiting | 1 |
| High-riding testis | 1 |
0–2 low, 3–4 intermediate, 5–7 high. A low score does not rule out torsion. Any concerning history, examination or diagnostic uncertainty requires immediate surgical review. Ultrasound must not delay exploration when suspicion is high.
Do not delay
Torsion is time-critical: document onset, give analgesia, keep nil by mouth and obtain urgent surgical/Urology review. Use the age route above before the score.