How to manage an 18-year-old with right testicular pain, normal ultrasound scrotum findings, and testicular volumes below the normal range for age?

Management of 18-Year-Old with Right Testicular Pain and Small Testicular Volume

For an 18-year-old with right testicular pain and normal ultrasound findings showing bilateral small testicular volumes, the recommended management includes urological referral for evaluation of testicular hypotrophy, while providing symptomatic treatment for the current pain episode. 1

Assessment of Current Findings

The ultrasound findings in this case show:

• Normal testicular contour and echotexture bilaterally
• Symmetric intratesticular vascularity
• Small bilateral epididymal head cysts (3mm each)
• No hydrocoele or varicocoele
• Testicular volumes below normal range for age (6ml right, 5ml left)
• No identifiable cause for the right testicular pain

Ruling Out Emergent Conditions

The normal intratesticular vascularity on ultrasound effectively rules out testicular torsion, which would present with decreased or absent blood flow 2, 1. The symmetric blood flow pattern and absence of focal lesions or inflammatory changes suggest that acute epididymitis or epididymo-orchitis is also unlikely.

Management Approach

1. Short-term pain management:

   • NSAIDs for pain relief
   • Scrotal support
   • Rest and avoidance of strenuous activities

2. Urological referral:

   • Non-urgent referral to urology for evaluation of bilateral testicular hypotrophy
   • Assessment of hormonal status (testosterone, FSH, LH)
   • Evaluation for potential causes of small testicular volume

3. Follow-up considerations:

   • If pain persists beyond 1-2 weeks despite conservative measures, earlier urological evaluation is warranted
   • Repeat ultrasound may be considered if new symptoms develop

Clinical Considerations

Potential Causes of Testicular Pain with Normal Ultrasound

Several conditions can cause testicular pain without obvious ultrasound findings:

• Referred pain from other sources (kidney stones, inguinal pathology)
• Intermittent torsion that resolved spontaneously
• Early or resolving epididymitis
• Testicular appendage torsion in resolution phase

Significance of Small Testicular Volume

Normal testicular volume for an 18-year-old is typically 15-25ml 1. The finding of bilateral small testes (5-6ml) warrants investigation as it may indicate:

• Hypogonadism
• History of cryptorchidism
• Chromosomal abnormalities
• Varicocele effects (though none currently visible)
• Other endocrine disorders

Common Pitfalls to Avoid

1. Dismissing the pain without follow-up: Even with normal ultrasound findings, persistent testicular pain requires evaluation 1.

2. Overlooking the significance of small testicular volume: This finding requires endocrine and fertility evaluation, particularly in a young adult 1.

3. Misdiagnosing as purely psychosomatic: Pain without obvious cause on imaging may still have a physiological basis that requires further investigation.

4. Focusing only on the pain while ignoring the developmental concern: The small testicular volume is potentially the more significant long-term issue despite being asymptomatic.

By addressing both the acute pain symptoms and the underlying testicular volume concerns, this approach provides comprehensive care for both the immediate complaint and potential long-term health implications.