What are the diagnostic steps and treatment options for a 10-year-old with testicular pain?

Evaluation and Management of Testicular Pain in a 10-Year-Old Child

For a 10-year-old presenting with testicular pain, immediate ultrasound duplex Doppler of the scrotum is the most appropriate initial diagnostic step, as testicular torsion must be ruled out urgently to prevent testicular loss. 1

Clinical Assessment

Key History Elements to Obtain:

• Onset and duration of pain (sudden vs. gradual)
• Severity and location of pain
• Associated symptoms (nausea, vomiting)
• Prior episodes of similar pain
• Recent trauma or physical activity
• Urinary symptoms
• Fever

Critical Physical Examination Findings:

• Testicular position and orientation
• Presence of scrotal swelling, redness, or edema
• Point of maximal tenderness (testis vs. epididymis)
• Prehn's sign (pain relief with testicular elevation suggests epididymitis)
• Cremasteric reflex (absence suggests torsion)
• "Blue dot sign" (pathognomonic for appendage torsion but only seen in 21% of cases) 1

Diagnostic Algorithm

1. Apply TWIST Score (Testicular Workup for Ischemia and Suspected Torsion) 2, 3:

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

   Interpretation:

   • Score ≥5: High risk (>90% risk of torsion) → Immediate urology consultation
   • Score 2-4: Intermediate risk → Urgent ultrasound
   • Score 0-1: Low risk → Consider ultrasound

2. Imaging:

   • Ultrasound duplex Doppler of the scrotum is the first-line imaging modality 1
   • Look for:
     • Blood flow to testicle (decreased/absent in torsion)
     • "Whirlpool sign" (twisted spermatic cord) - 96% sensitive, 99% specific 1, 2
     • Testicular echogenicity (heterogeneous in non-viable testis)
     • Epididymal enlargement or hyperemia (suggests epididymitis)
     • Hydrocele or scrotal wall thickening

Key Differential Diagnoses in 10-Year-Olds

1. Testicular Torsion:

   • Surgical emergency requiring intervention within 6 hours
   • Presents with sudden severe pain, swelling, high-riding testicle
   • Negative Prehn's sign
   • Decreased/absent blood flow on ultrasound 2

2. Torsion of Testicular Appendage:

   • Most common cause in prepubertal boys 1
   • Less severe pain than testicular torsion
   • Focal tenderness at upper pole
   • "Blue dot sign" when visible
   • Normal testicular blood flow on ultrasound

3. Epididymitis:

   • Gradual onset of pain
   • Positive Prehn's sign
   • May have associated urinary symptoms
   • Increased blood flow to epididymis on ultrasound

4. Idiopathic Scrotal Edema:

   • Usually painless
   • Marked scrotal wall thickening with striated appearance on ultrasound
   • Normal testes and epididymis 1

5. Intermittent Testicular Torsion:

   • History of recurrent episodes of acute scrotal pain that resolve spontaneously
   • Horizontal or hypermobile testes on examination 4

Management Based on Findings

• If high suspicion for testicular torsion (TWIST score ≥5 or suspicious ultrasound):

  • Immediate urology consultation without delay
  • Do not wait for imaging if clinical suspicion is high 2, 5
  • Consider manual detorsion while awaiting surgical intervention 5, 3

• If torsion of testicular appendage:

  • Conservative management with rest, scrotal support, and pain control
  • Urology follow-up

• If epididymitis:

  • Age-appropriate antibiotics if bacterial cause suspected
  • Anti-inflammatory medications
  • Scrotal support and rest

Critical Pitfalls to Avoid

1. Delaying surgical consultation when torsion is suspected clinically, even if waiting for imaging 2, 5
2. Misdiagnosing torsion as epididymitis (most common diagnostic error)
3. Relying solely on presence of cremasteric reflex to rule out torsion 5
4. Failing to recognize intermittent torsion in a child with recurrent testicular pain 4
5. Overlooking the possibility of torsion in a child with normal urinalysis 1

Remember that testicular salvage rates drop significantly after 6-8 hours of torsion, making this a true time-sensitive emergency 1, 2, 5.