What is the best approach for a patient with intermittent left testicular pain following trauma during sex, with recent negative G/C screening?

Management of Left Testicular Pain Following Trauma During Sexual Activity

Doppler ultrasound of the scrotum is the recommended first-line imaging for this patient with left testicular pain following trauma during sexual activity, as it can accurately diagnose testicular hematoma, rupture, and other traumatic injuries with high sensitivity and specificity. 1, 2

Clinical Assessment and Diagnostic Approach

• Pain characteristics: The patient reports:

  • Intermittent left testicular pain (2-3/10, max 5/10)
  • Radiation to left groin
  • Onset during sexual activity with associated trauma
  • No worsening over 2 days
  • No fever or other systemic symptoms

• Differential diagnosis to consider:

  • Testicular contusion/hematoma
  • Testicular rupture/fracture
  • Epididymitis (less likely given trauma history)
  • Testicular torsion (less likely given intermittent pain pattern)

Imaging Recommendations

• Scrotal ultrasound with Doppler is the initial imaging modality of choice 1, 2:

  • Grayscale imaging to evaluate:
    • Testicular parenchyma for heterogeneity or hypoechoic areas
    • Contour abnormalities
    • Disruption of tunica albuginea
    • Fracture lines
    • Intratesticular or extratesticular hematoma
  • Color Doppler to assess:
    • Testicular perfusion
    • Vascular integrity

• Timing: Given the stable, non-worsening pain and absence of severe symptoms, urgent but not emergent imaging is appropriate 2

Management Algorithm

1. If ultrasound shows normal findings or minor contusion:

   • Conservative management with:
     • Rest
     • Scrotal support/elevation
     • NSAIDs for pain control
     • Follow-up in 1-2 weeks if symptoms persist

2. If ultrasound shows testicular rupture (discontinuity of tunica albuginea):

   • Immediate urological consultation
   • Surgical exploration is indicated
   • Timely intervention improves testicular salvage rates 2, 3

3. If ultrasound shows hematoma without rupture:

   • Conservative management as above
   • Follow-up ultrasound in 2-4 weeks to ensure resolution 4
   • Continued monitoring until complete resolution to rule out underlying tumor 4

Important Considerations

• STI testing: While the patient declined in-house G/C testing citing a negative test from April 2025 and monogamous relationship, the provider appropriately recommended send-out testing to rule out infectious causes that could complicate trauma 1

• Follow-up: Essential to ensure complete resolution of any traumatic findings, as 10% of testicular tumors are found incidentally during trauma evaluation 4

• Red flags requiring immediate urological consultation:

  • Sudden worsening of pain
  • Development of fever
  • Significant swelling
  • Skin changes over the scrotum

Caveat

The combination of trauma history, stable mild-moderate pain, and absence of systemic symptoms suggests a less severe injury. However, testicular trauma requires proper imaging assessment as delayed diagnosis of testicular rupture can lead to loss of testicular function 3. Even in cases of mild trauma, ultrasound evaluation is essential to rule out significant injury requiring surgical intervention.