Testicular torsion is a relatively common urological emergency in which the spermatic cord and its contents are twisted, leading to testicular ischemia, which usually presents as sudden, severe scrotal pain. In comparison, testicular neoplasms are much less common in the emergency department, as they often present as painless hard masses that grow slowly over extended periods. Extremely rare cases of testicular neoplasms present as sudden scrotal pain causing a challenging task in the emergency department as physical examination and ultrasound findings may vary and not be specific enough to confirm the diagnosis.
In this case, we report a 22-year-old male referred by the emergency department (ED) as having a case of testicular torsion from presentation history; however, his physical examination and Doppler ultrasound findings were suspicious for testicular malignancy. The patient presented with a history of right scrotal pain for several hours with no predisposing factors; however, examination and imaging were highly suspicious for an underlying neoplasm. The patient underwent an inguinal orchiectomy and histology confirmed the presence of a germ cell tumor of several components.
In conclusion, a high index of suspicion for testicular torsion should always be present when a patient presents with sudden onset testicular pain; however, the differential diagnosis, including testicular neoplasms, should not be overlooked as it may alter treatment and outcome.
The annual incidence of testicular neoplasms is approximately two to three cases per 100,000 male population in the United States approximately 90%-95% of which are confirmed to be germ cell tumors . The most common presentation of a testicular neoplasm is a hard, painless, slow-growing mass felt in the scrotum . Nevertheless, they have occasionally presented themselves in other ways, such as chronic dullness or pain, a change in the shape of the testicles on palpation, or even a dull ache in the lower abdomen . However, the current literature describing acute painful presentations of testicular neoplasms shows a varying incidence, between 0.01% and 10%, of all cases. illustrating the scarcity of such a presentation in the overall incidence of testicular neoplasms in the general male population .
Unlike testicular cancer, testicular torsion is a relatively common urologic emergency, with the incidence in the United States reaching one in 4,000 men under the age of 25 each year. . It involves twisting the spermatic cord and its contents, leading to testicular ischemia and possible necrosis . These cases present with a sudden onset of severe pain in the scrotum, usually beginning within a few hours prior to presentation . As a result, the differential diagnosis of an intra-scrotal testicular tumor can be easily overlooked because most urologists, due to the high index of suspicion, put torsion at the top of the differential diagnosis in young patients with acute scrotal pain.
In this case, we report a 22-year-old male referred by the emergency department (ED) as having a case of testicular torsion from presentation history; however, his physical examination and Doppler ultrasound findings were suspicious for testicular malignancy.
A medically fit 22-year-old man presented to the ED with a history of right testicular pain for four hours. The patient reported that the pain had started acutely with no predisposing factors or trauma. On scrotal examination, the right hemiscrotum was found to be swollen and erythematous, with the right testis being extremely sensitive to the touch. In addition, a hard mass was also felt, and this was what initially raised the possibility of an underlying malignancy versus the first impression of testicular torsion. In addition, his initial examination, including a complete blood count and urinalysis, was unremarkable.
A color Doppler ultrasound (CDUS) was rushed and revealed a heterogeneous appearance of the right testis with no evidence of normal testicular tissues, as well as multiple macrocalcifications and cystic changes; however, no evidence of right spermatic cord torsion was noted (Figure 1).
Once these findings were observed, the diagnosis of a testicular neoplasm was strongly suspected. Consequently, the condition was discussed in detail with the patient and his family and they were informed of the possibility of an underlying testicular neoplasm. The patient was informed that he will require surgery for testicular exploration with a high probability of right orchiectomy via an inguinal approach.
In addition, preoperative blood tumor markers were sent and showed elevated alpha-fetoprotein (AFP) of 136.9 µg/L, beta-human chorionic gonadotropin (beta-HCG) of 942.1 mIU/mL, and lactate dehydrogenase (LDH) of 555 U/L. L which contributes to the diagnosis of an underlying testicular tumor. The patient was taken for an orchid orchidectomy of the right groin, and intraoperatively, the right testis looked like a hard mass without twisting the spermatic cord, confirming the absence of torsion of the testicles. The spermatic cord was ligated near the internal inguinal ring and an inguinal orchiectomy was performed with the appropriate testis sent for histopathological examination.
On day 2 postoperatively, the patient was discharged in stable condition. The right testicular histology report showed a mixed germ cell tumor with components described as 50% embryonic carcinoma, 35% teratoma and 15% yolk sac tumor with lymphovascular invasion. After histological confirmation of the diagnosis, a staging computed tomography (CT) scan of the chest, abdomen and pelvis was performed and lung metastasis was indicated with extensive involvement of the retroperitoneal and common iliac lymph nodes (Figure 2).
In addition, there was no evidence of bone or liver metastases. Based on this information, the staging of this patient’s neoplasm was considered to be T2N2M1. Finally, the case was presented in the National Tumor Board’s multidisciplinary team meeting and referred to the medical oncology team for further management.
Acute testicular pain in all prepubescent and young adult males should be considered testicular torsion until proven otherwise. This makes prompt diagnosis and treatment of paramount importance, as the earlier time to surgical intervention is directly proportional to the future viability of the testicles . Compared to the usual incidence of torsion per year, germ cell tumors in the testicles are relatively rare, accounting for only 1%-2% of cancers in men in the United States .
The recognized presentation of testicular neoplasms usually contradicts that of testicular torsion, with the former presenting as a slow-growing painless mass over months and the latter as a sudden severe scrotal pain over hours  which adds to the difficulty in diagnosing neoplasms, which present with sudden scrotal pain. An example of a case where a tumor presented with acute pain leading to misdiagnosis was reported by Alrabeeah et al. in 2017  who described a case of testicular seminoma that presented as an acute scrotum . He described the causes that led to the masking of the diagnosis, in which case the inability to properly assess the testis on physical examination, caused by the surrounding scrotal edema, as well as the non-specific changes on ultrasound, which led to a preliminary diagnosis. of epididymo-orchitis. This ultimately led to delays in ideal business operations . That said, the causes of sudden scrotal pain in patients with testicular cancer have been previously described in the literature and were mostly attributed to the tumor itself. It was noted that in such cases there was evidence of intratesticular bleeding in the tumor itself or even torsion due to the massive effect of the tumor, both caused testicular cancer to present as acute scrotum .
In addition, color Doppler ultrasound has been reported to have a high sensitivity of 100%  and specificity of 97.9%  and is an invaluable tool that aids in the diagnosis of testicular torsion versus other pathologies. However, in the rare case of a testicular neoplasm with acute pain, the diagnosis may be obscured by either severe scrotal edema or even concomitant torsion caused by the tumor itself . Therefore, the high index of suspected testicular torsion should always be the priority when a patient presents with sudden onset testicular pain, but testicular neoplasms should never be overlooked within the differential diagnosis. This is important because it changes both the surgical approach and the patient’s right to be informed that an orchidectomy will need to be performed as opposed to an isolated case of testicular torsion, where the main goal is to perform an orchidopexy. and rescue the torn man. testis.
In conclusion, as illustrated in this case, good physical examination and CDUS aided in early recognition of the underlying testicular neoplasm rather than testicular torsion, and this prevented immediate scrotal exploration by a scrotal approach; however, as evidenced by the sparse literature on similar cases, the diagnosis can easily be missed.