Acute Scrotum Masquerading as Testicular Torsion: Spontaneous Intratesticular Hematoma in a Patient With Congenital Afibrinogenemia.

Congenital afibrinogenemia is an exceedingly rare autosomal recessive bleeding disorder characterized by the complete absence of circulating fibrinogen, predisposing affected individuals to spontaneous and trauma-related hemorrhage at virtually any anatomical site. Acute scrotal pain, by contrast, is a common urological emergency in which testicular torsion must be excluded promptly, as diagnostic delay risks irreversible testicular loss. We describe a 31-year-old man with known congenital afibrinogenemia, maintained on periodic fibrinogen concentrate replacement, who presented with acute right testicular and inguinal pain out of proportion to initial findings, accompanied by nausea. Examination revealed a tender, swollen, firm, high-riding right testis with an absent cremasteric reflex, a constellation corresponding to the maximum possible Testicular Workup for Ischemia and Suspected Torsion (TWIST) score of seven points and strongly suggestive of torsion. Manual detorsion was attempted, with partial symptomatic improvement. Scrotal Doppler ultrasonography, performed after an attempted manual detorsion with partial symptomatic improvement, demonstrated preserved, symmetric flow with no evidence of torsion at the time of imaging, alongside avascular, hypoechoic, geographic intratesticular regions most consistent with intratesticular hematoma in the context of the patient's coagulopathy. Multidisciplinary management by emergency medicine, urology, and hematology favored conservative treatment with intravenous fibrinogen concentrate and analgesia over surgical exploration, given both the sonographic findings of preserved perfusion and no evidence of torsion and the prohibitive hemorrhagic risk that surgery would pose in a patient with a complete absence of fibrinogen. The patient was discharged with a plan for follow-up imaging and multidisciplinary outpatient review. This case illustrates that spontaneous intratesticular hemorrhage can closely mimic testicular torsion on history and examination, even fulfilling maximal clinical risk-scoring criteria, and underscores the pivotal role of prompt Doppler ultrasonography in guiding safe, conservative management in patients for whom surgery carries extreme bleeding risk. Awareness of this rare mimicker is essential for clinicians managing acute scrotal pain in patients with severe inherited coagulopathies.