From the Guidelines
For testicular pain, I would recommend both stat urology consultation and stat ultrasound. Acute testicular pain requires urgent evaluation to rule out testicular torsion, which is a surgical emergency requiring intervention within 4-6 hours to save the testicle 1. While the urologist's clinical examination is valuable, ultrasound provides crucial information about testicular blood flow and can help differentiate between torsion, epididymitis, orchitis, or other causes of pain 1. The combination of both approaches offers the most comprehensive assessment.
Key Considerations
- Ultrasound findings can guide the urologist's decision-making process regarding the need for immediate surgical exploration versus medical management.
- Even if torsion is clinically suspected, the ultrasound can confirm the diagnosis and assess the viability of the testicle.
- In cases where the clinical picture is unclear, the imaging can prevent unnecessary surgical exploration for conditions like epididymitis that can be treated with antibiotics.
Diagnostic Approach
- The use of color Doppler, power Doppler, and spectral Doppler US allows for the evaluation of testicular perfusion and can help identify testicular torsion 1.
- The "whirlpool sign" on grayscale imaging, which refers to a spiral twist of the spermatic cord, is a specific US sign of torsion 1.
- US findings in patients with epididymitis include an enlarged and hypoechoic epididymis due to edema, reactive hydroceles, and scrotal wall thickening, with increased blood flow corresponding to hyperemia on color Doppler imaging 1.
Treatment Implications
- Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss in cases of testicular torsion 1.
- For epididymitis, treatment with antibiotics such as ceftriaxone 250mg IM plus doxycycline 100mg BID for 10 days for suspected sexually transmitted infections, or levofloxacin 500mg daily for 10 days for other causes, may be appropriate 1.
From the Research
Urgent Referral for Testicular Pain
- A patient with testicular pain should be referred for urgent (stat) urology consultation, as testicular torsion is a surgical emergency that requires prompt attention 2, 3.
- The use of urgent ultrasound in addition to urology consultation is not universally recommended, as some studies suggest that it may not be necessary in all cases and can potentially lead to delays in surgical management 4, 3.
- However, ultrasound can be a useful diagnostic tool in evaluating testicular pain, particularly in cases where the diagnosis is unclear 2, 4.
- The decision to refer a patient for urgent urology consultation and ultrasound should be based on a thorough clinical evaluation, including a detailed history and physical examination 5, 6.
- It is essential to have a high index of suspicion for testicular torsion, as delayed diagnosis and treatment can result in testicular loss 4, 5.