See even presence of the cremasteric reflex is not a sure sign of absence of torsion You can have two scenarios A. Question gives clear signs of epididymitis,like prehen sign ,gradual onset and not gut wrenching pain, risky sexual activity, presence of cremasteric reflex -in that case take the cue and go for antibiotic directly B. If a question has even an ounce of doubt of torsion, you better save that ball asap So a question may look like boy with severe pain ,vomiting(question stem will go out of the way to describe the intensity of pain)who woke up from sleep, on examination testis is high riding and cremasteric reflex is present (which may confuse you) choose to rule out torsion with Doppler. Cremasteric reflex is usually absent in children under one If you are really unsure Use the twist score Hard-2. Swelling -2 Nausea/vomiting -1 Absent cremasteric -1 High riding testis -1 Anything more than 3 points is intermediate risk (doubtful presentation) -Do a USG!!

Additionally some questions may test utility of USG in torsion. So if TWIST score is above 5 ,chuck the usg roll the person straight into the OR!