What is the initial workup and management for an 18-year-old with left-sided testicular pain in primary medicine?

Initial Workup and Management for Left-Sided Testicular Pain in an 18-Year-Old

For an 18-year-old male with left-sided testicular pain, immediate testicular ultrasound with Doppler is essential to rule out testicular torsion, which is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss. 1

Initial Assessment

Urgent Evaluation for Testicular Torsion

• Testicular torsion must be ruled out first due to high risk in adolescents
• Key clinical features suggesting torsion:
  • Sudden onset of severe pain
  • Absence of urinary symptoms
  • Negative Prehn's sign (pain not relieved by testicular elevation)
  • Absent cremasteric reflex
  • High-riding or horizontal testis position

TWIST Score Assessment

The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score should be calculated 1, 2:

• Testicular swelling (2 points)
• Hard testicle (2 points)
• Absent cremasteric reflex (1 point)
• Nausea/vomiting (1 point)
• High-riding testis (1 point)

Score interpretation:

• Score ≥5: High risk (consider immediate surgical exploration)
• Score 2-4: Intermediate risk (requires urgent ultrasound)
• Score 0-1: Low risk (ultrasound still recommended)

Diagnostic Workup

1. Imaging

• Scrotal Ultrasound with Doppler: First-line imaging test 1
  • Evaluates testicular blood flow
  • Identifies "whirlpool sign" of twisted spermatic cord
  • Assesses for epididymal enlargement or other pathology
  • Sensitivity 96-100%, specificity 84-95% for torsion

2. Laboratory Tests

• Urinalysis: To evaluate for infection
• Urine culture: If epididymitis suspected
• STI testing: For sexually active patients
  • Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
• CBC: To assess for systemic infection
• Consider syphilis serology and HIV testing if STI suspected 1

Management Algorithm

If Testicular Torsion Suspected:

1. Immediate urology consultation
2. Attempt manual detorsion while awaiting definitive care
3. Emergency surgical exploration within 6 hours of symptom onset
4. Bilateral orchiopexy if testis is viable

If Epididymitis Diagnosed:

1. Antimicrobial therapy based on likely etiology 1:

   • For likely STI origin (age <35 years):
     • Ceftriaxone 250 mg IM single dose PLUS
     • Doxycycline 100 mg orally twice daily for 10 days
   • For likely enteric organisms or patients >35 years:
     • Levofloxacin 500 mg orally once daily for 10 days OR
     • Ofloxacin 300 mg orally twice daily for 10 days

2. Supportive measures:

   • Bed rest
   • Scrotal elevation
   • Analgesics
   • NSAIDs for inflammation

3. Follow-up:

   • Reassessment within 3 days if not improving
   • Partner notification and treatment if STI confirmed

Common Pitfalls to Avoid

1. Delayed diagnosis: Never assume epididymitis without ruling out torsion first, especially in adolescents

2. Misdiagnosis based on urinalysis: Patients with torsion can have normal urinalysis; this does not exclude epididymitis 1

3. Age-based assumptions: While torsion is rare in men >35 years, it can occur at any age 3

4. Incomplete evaluation: Always perform bilateral scrotal examination and ultrasound

5. Missing intermittent torsion: Consider this in patients with recurrent testicular pain episodes 4

6. Inadequate follow-up: Failure to improve within 3 days requires reevaluation of diagnosis and treatment 1

Remember that testicular torsion is a time-sensitive emergency where delays directly impact testicular salvage rates. When in doubt, early surgical exploration is preferred over observation.