DRIUrology clinical guide
Draft clinical resource — local clinical approval required before intranet publication

Urology Emergency management

Acute testicular pain and paraphimosis

Treat suspected torsion as time-critical and base infection treatment on clinical risk, not age alone.

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Acute scrotal pain flowchart

  1. Suspected torsion: establish age firstThis determines the immediate local receiving service; do not delay simultaneous assessment, analgesia or escalation.
  2. 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.
  3. Immediate actions for both age groupsRecord onset, assess ABCDE, provide analgesia, keep nil by mouth and examine the abdomen, groins and both testes.
  4. Torsion cannot be excluded?Sudden severe pain, abnormal lie/high testis, nausea/vomiting, absent cremasteric reflex or diagnostic uncertainty.
  5. 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.
  6. Sepsis, abscess concern or worsening symptoms?Include immunocompromise and inability to tolerate treatment.
  7. Yes — admit/discuss urgentlyUse sepsis guidance and obtain senior/Urology input.
    No — targeted treatmentUse BASHH risk-based tests and current DBTH antimicrobials, with review and safety-netting.

Focused assessment

History

  • Exact onset, severity, nausea/vomiting and previous episodes
  • Trauma, urinary symptoms, STI risk and recent instrumentation
  • Fertility history, undescended testis, surgery and immunocompromise

Examination

  • Inspect and palpate both testes, epididymides and spermatic cords
  • Testicular lie, tenderness, swelling, cremasteric reflex and groins
  • Abdomen and perineum; do not let examination uncertainty delay escalation

Investigations

  • Torsion is primarily a clinical emergency: urgent surgical decision first
  • Urinalysis/culture and STI testing for likely infection
  • Ultrasound only when it will resolve uncertainty without harmful delay

Suspected testicular torsion

Testicular torsion is a time-critical surgical emergency. Arrange immediate senior surgical/Urology assessment. Nil by mouth, provide analgesia, document time of pain onset and examination findings, and follow the agreed emergency theatre pathway.

Ultrasound must not delay urgent surgical assessment or exploration when clinical suspicion is high. Torsion can occur outside the typical adolescent age range.

Possible epididymo-orchitis

  1. Exclude torsion first. Assess sexual history, urinary symptoms, recent instrumentation, urinary-tract abnormality and systemic illness.
  2. Obtain recommended STI and urine tests where appropriate without delaying treatment in a clinically established infection.
  3. Choose empirical antimicrobials using the BASHH pathway and current DBTH antimicrobial guidance. Do not use the supplied “doxycycline below 30 / ciprofloxacin above 30” age-only rule.
  4. Admit or seek urgent advice for sepsis, severe/worsening pain, abscess concern, inability to tolerate treatment or diagnostic uncertainty.

Paraphimosis

Provide analgesia and attempt prompt manual reduction by a competent clinician using an agreed technique. Contact Urology urgently if reduction fails, tissue ischaemia/necrosis is suspected, the diagnosis is uncertain, or the patient is a child requiring specialist support.