A 17-year-old boy with a known history of a left undescended testis presented with a 3-day history of left lower quadrant (LLQ) abdominal pain. During the initial three days, he had sought medical attention several times at primary care facilities. However, he did not report his history of undescended testis to the physicians, and physical examination of the testis was reportedly inconclusive during the initial visits.
As the pain progressively worsened and was accompanied by nausea and vomiting, he presented to the emergency department of a hospital in his hometown. Abdominal and pelvic ultrasonography demonstrated an undescended left testis located at the proximal inguinal canal, measuring less than 1 cm in size. The testis appeared twisted, with markedly reduced blood flow on Doppler examination, raising strong suspicion of testicular torsion.
The patient was subsequently referred to a specialized urology center for further evaluation and management.
Given the clinical presentation and Doppler ultrasonography findings suggestive of torsion of the undescended left testis, the patient underwent surgical exploration. The undescended, torsed left testis was found to be nonviable, and an orchiectomy was performed.
The postoperative course was uneventful. By the first postoperative day, the patient's abdominal pain had completely resolved, and his associated symptoms showed significant improvement. He was subsequently discharged with appropriate follow-up.
Clinical Significance
This case highlights the importance of including a thorough genitourinary examination in adolescent males presenting with lower abdominal pain. A careful history should specifically address previous urological conditions, including a history of an undescended testis.
Testicular torsion involving an undescended testis may present atypically, particularly with abdominal or lower abdominal pain rather than the classic acute scrotal presentation. Failure to identify the history of cryptorchidism or to examine the testes may result in delayed diagnosis and potentially irreversible testicular ischemia.
Therefore, in adolescent boys presenting with acute or unexplained lower abdominal pain, a focused genital examination and detailed urological history should be considered essential components of the initial clinical assessment.
Discussion and Literature Review
Cryptorchidism is a relatively common congenital urological condition, affecting approximately 0.8–1% of boys beyond infancy. Although an undescended testis is associated with an increased risk of malignancy and infertility, torsion of an undescended testis is considered a rare complication. The true incidence of torsion in undescended testes is not well established because the condition is uncommon and the available literature consists predominantly of isolated case reports and small case series.
In a retrospective series of 13 patients with torsion of an undescended testis, only six testes could be preserved, whereas seven patients underwent orchiectomy, mainly because of testicular gangrene. Delayed presentation was common, with only 30.7% of patients presenting within 6 hours of symptom onset. The authors emphasized that torsion of an undescended testis is frequently diagnosed late because of its atypical clinical presentation.
A larger pediatric series reported nine cases of torsion of an undescended gonad among 192 boys operated on for testicular torsion over a 10-year period, accounting for 4.7% of all testicular torsion cases in that cohort. These nine cases represented 0.95% of 860 boys who underwent surgery for cryptorchidism. Abdominal pain, vomiting, and fever were reported among the associated systemic manifestations.
Several published case reports describe adolescents presenting with abdominal pain rather than the typical acute scrotal presentation. Notably, a 17-year-old boy with torsion of an undescended testis located in the inguinal canal was reported to present with lower abdominal pain and subsequently undergo orchiectomy. Other reports have described 16-year-old patients presenting with iliac fossa pain and vomiting due to torsion of an intra-abdominal undescended testis.
These reports closely resemble the clinical scenario in our patient and emphasize an important diagnostic pitfall: when the testis is undescended, torsion may manifest as lower abdominal or inguinal pain without the classic features of acute scrotal pain. Consequently, a history of cryptorchidism should be specifically sought, and examination of the external genitalia and inguinoscrotal region should be considered an essential component of the evaluation of adolescent males presenting with unexplained acute abdominal or groin pain. Early recognition and urgent surgical exploration are critical to maximize the possibility of testicular salvage.
presented by: Dr Dadpour , Dr Montazeri