From the Guidelines
Differentiating between epididymoorchitis and testicular torsion is crucial, and the most recent evidence suggests that key signs of testicular torsion include sudden, severe unilateral testicular pain, high-riding testis with horizontal lie, absent cremasteric reflex, and nausea/vomiting, whereas epididymoorchitis presents with gradual onset of pain, scrotal erythema and edema, urinary symptoms, fever, and pain relief with scrotal elevation. The pain typically does not improve with scrotal elevation (negative Prehn's sign) in testicular torsion, in contrast to epididymoorchitis, which shows pain relief with scrotal elevation (positive Prehn's sign) 1.
Key Signs and Symptoms
- Testicular torsion: sudden, severe unilateral testicular pain, high-riding testis with horizontal lie, absent cremasteric reflex, and nausea/vomiting
- Epididymoorchitis: gradual onset of pain, scrotal erythema and edema, urinary symptoms (dysuria, frequency), fever, and pain relief with scrotal elevation
Treatment Approaches
- Testicular torsion requires emergency surgical exploration and detorsion within 6 hours to prevent testicular loss, followed by bilateral orchiopexy
- Epididymoorchitis treatment involves antibiotics (ceftriaxone 250mg IM once plus doxycycline 100mg twice daily for 10 days for suspected STI cases, or ciprofloxacin 500mg twice daily for 10-14 days for non-STI cases), NSAIDs for pain (ibuprofen 400-600mg three times daily), scrotal support, and rest 1
Diagnostic Tools
- Color Doppler ultrasound can help differentiate the conditions by showing decreased or absent blood flow in torsion versus increased flow in epididymoorchitis
- The "whirlpool sign" on ultrasound, referring to a spiral twist of the spermatic cord, is a specific sign of torsion 1
- Reactive hydroceles and scrotal wall thickening can also be seen in epididymoorchitis, with increased blood flow corresponding to hyperemia on color Doppler imaging 1
Clinical Considerations
- When in doubt, surgical exploration is warranted as the consequences of missed torsion are permanent testicular damage
- Clinical assessment, including the presence of fever, waxing and waning pain, and laboratory markers for infection, must be integrated to distinguish between testicular torsion and epididymoorchitis 1
From the Research
Key Signs of Epididymoorchitis and Testicular Torsion
- Epididymoorchitis typically presents with a gradual onset of scrotal pain, swelling of the epididymis, and symptoms of lower urinary tract infection, including fever 2.
- Testicular torsion is a surgical emergency that presents with sudden, severe testicular pain, often accompanied by nausea and vomiting 3.
- The cremasteric reflex is often absent in testicular torsion, but present in epididymoorchitis 2.
Treatment Approaches
- Epididymoorchitis is usually treated with antibiotics, such as ceftriaxone and doxycycline for Chlamydia trachomatis and Neisseria gonorrhoeae, or ofloxacin or levofloxacin for coliform bacteria 2.
- Testicular torsion requires immediate surgical intervention to preserve the testicle, with a window of 4-6 hours for optimal outcomes 4, 3.
- In cases where epididymoorchitis is suspected, close follow-up and adequate counseling are crucial to monitor for potential complications, such as testicular torsion or ischemia 5, 6.
Differential Diagnosis
- The diagnosis of epididymoorchitis and testicular torsion can be challenging, and a high index of suspicion is necessary to differentiate between the two conditions 5, 4.
- Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, can help guide therapy and differentiate between the two conditions 2.
- Urgent scrotal exploration is advised in every case of acute testicular pain unless there is overwhelming evidence of epididymoorchitis 3.