From the Guidelines
The treatment approach for differentiating between testicular torsion and epididymoorchitis requires immediate urological consultation and diagnostic imaging, as testicular torsion is a surgical emergency. According to the most recent guidelines 1, color Doppler ultrasound is the preferred initial imaging study, with decreased or absent blood flow suggesting torsion while increased flow indicates epididymoorchitis.
Key Considerations
- If testicular torsion is suspected clinically, immediate surgical exploration is warranted without waiting for imaging results, as delays beyond 6 hours significantly increase the risk of testicular loss 1.
- For confirmed testicular torsion, manual detorsion may be attempted as a temporizing measure, followed by definitive surgical correction with orchiopexy of both testes.
- If epididymoorchitis is diagnosed, treatment includes antibiotics (typically ceftriaxone 250mg IM once plus doxycycline 100mg twice daily for 10 days for sexually transmitted infections, or fluoroquinolones like ciprofloxacin 500mg twice daily for 10-14 days for non-STI cases) 1, anti-inflammatory medications, scrotal support, and rest.
Diagnostic Approach
- The use of a clinically validated scoring system, such as the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, can help in the diagnosis of testicular torsion, especially in pediatric patients 1.
- Ultrasound findings, including the "whirlpool sign" and decreased or absent blood flow, can aid in the diagnosis of testicular torsion 1.
- The presence of fever, waxing and waning pain, and laboratory markers for infection should be integrated into the clinical assessment to distinguish between testicular torsion and epididymoorchitis 1.
From the Research
Differentiating between Testicular Torsion and Epididymoorchitis
The treatment approach for differentiating between testicular torsion and epididymoorchitis involves several key considerations:
- Clinical Presentation: Acute, severe, unilateral scrotal pain is the most common presenting symptom of testicular torsion, while epididymoorchitis typically presents with pain, swelling, and inflammation of the epididymis and testis 2, 3.
- Diagnostic Tools: The TWIST score, which is based on clinical parameters such as testicular swelling, hard testicle, absent cremasteric reflex, nausea/vomiting, and high-riding testis, can assist with clinical decision making in patients presenting with acute testicular pain 4.
- Imaging Studies: Ultrasound, particularly color Doppler, can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis of testicular torsion 3, 5.
- Risk Factors: The presence of a bell-clapper deformity is a key risk factor for testicular torsion, and patients with epididymoorchitis should be closely monitored for signs of subsequent torsion 2, 3.
Treatment Approach
The treatment approach for testicular torsion and epididymoorchitis differs:
- Testicular Torsion: Emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED, is necessary to prevent testicular loss 3, 5.
- Epididymoorchitis: Treatment typically involves antibiotics and supportive care, and patients should be closely monitored for signs of complications, such as abscess formation or testicular torsion 2, 6.
Key Considerations
- Time-Sensitive Diagnosis: Testicular torsion is a time-sensitive diagnosis, and delayed treatment can result in testicular loss 3, 5.
- Close Follow-Up: Patients with epididymoorchitis should be closely monitored for signs of subsequent torsion, and adequate counseling on warning signs is essential to intervene early and prevent testicular loss 2.