Surgical referral – this is the mainstay of treatment for torsion and gangrene. 

Analgesia – multimodal analgesia is important and should include comfortable positioning, support, application of ice, use of Entonox where not contraindicated, paracetamol, ibuprofen, codeine/oral morphine. Consider intranasal opiates in children where IV access has yet to be established, if appropriate.

Antibiotics: the two main presentations requiring antibiotic cover are epididymo-orchitis and Fournier gangrene. Local cellulitis is a potential, but is a diagnosis of exclusion. Ensure patients being discharged have appropriate follow up arranged, patient information needs addressed and primary care informed

Learning Bite

Know your local pathways for torsion and gangrene, and focus on addressing the rate limiting steps such as referral and access for analgesia and antibiotics. For other presentations, ensure appropriate follow up is arranged where patients are discharged from the ED.