What is the appropriate evaluation and management for a 24-year-old male presenting with left testicular pain radiating to the left groin?

Evaluation and Management of Left Testicular Pain in a 24-Year-Old Male

Doppler ultrasound of the scrotum is the first-line diagnostic test for a 24-year-old male with left testicular pain radiating to the left groin, as it has high sensitivity (96-100%) and specificity (84-95%) for detecting testicular torsion and other causes of acute scrotal pain. 1

Immediate Assessment and Differential Diagnosis

The three most common causes of acute scrotal pain in a young adult male are:

1. Testicular torsion (surgical emergency)
2. Epididymitis/orchepididymitis (most common in adults)
3. Torsion of the testicular appendix

Other potential causes include:

• Varicocele
• Testicular tumor
• Hydrocele
• Referred pain from other sources (e.g., kidney stones, appendicitis)

Critical Risk Assessment

For testicular torsion, time is critical:

• The window for optimal testicular salvage is less than 6-8 hours from symptom onset 1
• Salvage rates drop significantly after this time window

Diagnostic Approach

1. Clinical Evaluation

Look specifically for:

• Sudden onset of severe pain
• Nausea/vomiting (strongly associated with torsion)
• Absence of ipsilateral cremasteric reflex (highly predictive of torsion)
• Abnormal testicular position
• Scrotal skin changes 2

2. Imaging

• Doppler ultrasound is the initial imaging modality of choice with sensitivity 69-96.8% and specificity 87-100% 1
  • Should include grayscale imaging to evaluate testicular parenchyma, epididymal enlargement, hydrocele, scrotal wall thickening
  • Color and power Doppler to assess testicular perfusion patterns

Key ultrasound findings:

• Testicular torsion: Decreased or absent blood flow, possible "whirlpool sign" (96% sensitivity, 99% specificity)
• Epididymitis: Increased blood flow to epididymis, enlarged and hypoechoic epididymis
• Torsion of testicular appendix: Hypoechoic appendix with or without flow 1

Management Algorithm

1. If high clinical suspicion for testicular torsion:

   • Do not delay for imaging
   • Immediate urological consultation
   • Manual detorsion can be attempted while waiting for surgical intervention 1, 3

2. If ultrasound confirms epididymitis:

   • Conservative treatment with:
     • Rest
     • Scrotal support
     • Pain control
     • Appropriate antibiotics
     • Urological follow-up 1

3. If ultrasound confirms torsion of testicular appendix:

   • Conservative treatment with:
     • Rest
     • Scrotal support
     • Pain control 1

4. If ultrasound is normal but pain persists:

   • Consider referred pain from other sources
   • Evaluate for inguinal hernia
   • Consider additional imaging if clinically indicated

Clinical Pitfalls and Caveats

• Do not delay urological consultation if testicular torsion is suspected clinically, even if waiting for imaging 3
• Testicular torsion can occur at any age, not just in adolescents 4
• The testicle can torse and detorse spontaneously, creating a confusing clinical picture 5
• Always examine both testicles, even if pain is unilateral 1
• Consider rare but serious conditions such as testicular tumor or cryptorchidism with torsion in patients with atypical presentations 6
• Radionuclide imaging has been largely replaced by Doppler ultrasound for evaluation of acute scrotal pain 7

Remember that in cases of testicular torsion, time-to-treatment directly correlates with testicular salvage rates, making rapid diagnosis and management essential to preserve testicular function and fertility.