may be referred to the abdomen, genitalia should be examined carefully in every child who complains of abdominal pain Urinalysis is usually negative The diagnosis of testicular torsion is made clinically when unilateral, acute scrotal pain presents with testicular changes, absent cremasteric reflex, and associated nausea or vomiting Immediate surgical consultation for exploration and repair, without delay for imaging, is optimal A clinical scoring system (ranging from to 7) that takes into account the presence of nausea or vomiting (1 point), testicular swelling (2 points), hard testis on palpation (2 points), highriding testis (1 point), and absent cremasteric reflex (1 point) has been derived and validated In multiple studies, a high-risk score of accurately identifies testicular torsion with 100% specificity and 100% positive predictive value for torsion Use of a validated risk-scoring system should be incorporated into a workflow to obtain prompt urological consultation and expediate surgical management of testicular torsion Color Doppler ultrasound evaluates the size, shape, echogenicity, and perfusion of the testes and associated structures, and confirms the absence of torsion In testicular torsion there is decreased or absent arterial blood flow within the affected testicle ( Fig 61.4 ) With high sensitivity (88.9%) and specificity (98.8%) and a low false-negative rate of 1%, ultrasound is the first-line imaging modality False-positive scans occur when testicular flow appears decreased due to a large hydrocele, abscess, hematoma, or hernia False-negative ultrasounds occur from spontaneous detorsion, partial or intermittent torsion, or late torsion when severe, overlying scrotal edema with increased vascularity obscures the underlying ischemic testis Limitations of Doppler sonography exist in small, lower flow prepubertal testes and due to operator-dependent nature of this test Previously used nuclear perfusion scans are limited by associated time delay and radiation exposure Again, imaging should not delay surgical consultation or treatment, as this can prolong testicular ischemia and may increase the likelihood of testicular loss