What is the initial workup and management for a patient presenting to the emergency department (ED) with testicular pain?

Initial Workup and Management for Testicular Pain in the Emergency Department

Duplex Doppler ultrasound of the scrotum is the essential first-line imaging study for all patients presenting to the emergency department with acute testicular pain to rule out testicular torsion, which is a surgical emergency requiring intervention within 6-8 hours. 1

Immediate Clinical Assessment

History - Key Elements to Obtain:

• Onset of pain (sudden vs. gradual)
• Duration of symptoms (hours vs. days)
• Pain characteristics (severity, radiation)
• Associated symptoms (nausea/vomiting)
• Sexual activity history
• Urinary symptoms
• Previous episodes or trauma

Physical Examination - Critical Findings:

• Testicular position (high-riding testis suggests torsion)
• Testicular orientation (horizontal orientation suggests torsion)
• Cremasteric reflex (absent in torsion)
• Prehn's sign (pain relief with testicular elevation suggests epididymitis)
• "Blue dot sign" (pathognomonic for appendage torsion, but only seen in 21% of cases)
• Scrotal skin changes (erythema, edema)

Diagnostic Algorithm

1. High Clinical Suspicion for Testicular Torsion:

   • Sudden onset of severe pain
   • Absent cremasteric reflex
   • High-riding or horizontally oriented testicle
   • Nausea/vomiting
   • Scrotal skin changes
   • → Immediate urology consultation without waiting for imaging 1, 2

2. Moderate Clinical Suspicion:

   • TWIST Score assessment (Testicular Workup for Ischemia and Suspected Torsion)
     • Testicular swelling (1 point)
     • Hard testicle (1 point)
     • Absent cremasteric reflex (1 point)
     • Nausea/vomiting (1 point)
     • High-riding testis (1 point)
   • Score ≥5: High risk (92.9% positive predictive value) → Immediate urology consultation
   • Score <5: Proceed to imaging 1, 3

3. All Other Presentations:

   • Immediate Duplex Doppler ultrasound of the scrotum 1
   • Consider point-of-care ultrasound if available and provider is trained 4, 5

Imaging Findings Interpretation

Testicular Torsion:

• Decreased or absent blood flow on Doppler
• "Whirlpool sign" (twisted spermatic cord) - 96% sensitivity, 99% specificity
• Heterogeneous testicular echotexture (in later stages)

Epididymitis/Epididymo-orchitis:

• Increased blood flow on Doppler
• Enlarged, hypoechoic epididymis
• Possible reactive hydrocele

Torsion of Testicular Appendage:

• Normal testicular blood flow
• Focal hyperemia adjacent to upper pole
• Possible visualization of the twisted appendage

Management Based on Diagnosis

Testicular Torsion:

• Immediate urology consultation for surgical exploration
• Consider manual detorsion while awaiting surgery (can be guided by point-of-care ultrasound)
• Surgical exploration within 6-8 hours of symptom onset for best chance of testicular salvage 1, 5

Epididymitis/Epididymo-orchitis:

• Age 14-35 years: Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days
• Age >35 years: Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days
• Supportive care: scrotal elevation, analgesics, rest, adequate hydration 3
• Consider admission for severe pain, fever, or concerns about compliance

Torsion of Testicular Appendage:

• Conservative management with analgesics
• Scrotal support
• Rest and ice

Important Pitfalls to Avoid

1. Delayed Diagnosis: Testicular torsion is a surgical emergency with time-dependent outcomes. Do not delay urology consultation when clinical suspicion is high.

2. Over-reliance on Single Findings: No single finding is 100% sensitive or specific for any diagnosis. Use a constellation of findings.

3. Missing Underlying Pathology: Rarely, testicular tumors can present with acute pain mimicking torsion. Ensure follow-up for persistent abnormalities. 6

4. Incomplete Evaluation: Always examine both testicles, even when pain is unilateral.

5. Inadequate Pain Control: Provide appropriate analgesia while diagnostic workup is ongoing.