Workup of Testicular Pain
The initial evaluation of testicular pain should include a focused history, physical examination, and prompt scrotal ultrasound with Doppler imaging to rule out testicular torsion, which is a surgical emergency requiring immediate intervention. 1
Initial Assessment
History
- Onset of pain (sudden vs. gradual)
- Duration of symptoms
- Associated symptoms (nausea, vomiting)
- Recent trauma or sexual activity
- Previous episodes
- Fever
Physical Examination
Key findings to differentiate between common causes:
| Finding | Suggests Torsion | Suggests Epididymitis |
|---|---|---|
| Onset | Sudden | Gradual |
| Prehn sign (pain relief with elevation) | No | Yes |
| Cremasteric reflex | Absent | Present |
| Testicular position | High-riding | Normal |
| Associated symptoms | Nausea/vomiting | Fever, dysuria |
Diagnostic Algorithm
Immediate Surgical Exploration without delay for imaging if:
Urgent Scrotal Ultrasound with Doppler if:
- Clinical picture is unclear
- Symptoms are less than 24 hours
- Torsion is in the differential but not clearly evident 1
Laboratory Testing if epididymitis is suspected:
- Urethral swab or first-void urine for STI testing
- Urinalysis and urine culture 1
Interpretation of Imaging
- Testicular Torsion: Decreased or absent blood flow on Doppler ultrasound
- Epididymitis: Increased blood flow on Doppler ultrasound
- Torsion of Testicular Appendage: Normal testicular blood flow with focal hyperemia 1, 3
Important Clinical Pearls
- Time is critical in testicular torsion - there is typically a 4-8 hour window before permanent ischemic damage occurs 2
- Do not delay surgical exploration for imaging studies if clinical suspicion for torsion is high 2
- The sensitivity and specificity of Doppler ultrasound for testicular torsion are approximately 97% and 89%, respectively 3
- Point-of-care hand-held Doppler may be used as a first-line triaging tool in emergency departments with a specificity of 97.8% for ruling out testicular torsion 4
Common Pitfalls to Avoid
- Misdiagnosing testicular torsion as epididymitis can lead to testicular loss
- Relying solely on the presence of a single physical finding (many findings overlap between conditions)
- Delaying surgical consultation when torsion is suspected
- Failing to arrange close follow-up for patients with negative imaging but persistent symptoms 5
Management Based on Diagnosis
- Testicular Torsion: Immediate urological consultation for surgical exploration
- Epididymitis:
- Age <35 years (likely STI): Ceftriaxone 250 mg IM single dose plus Doxycycline 100 mg orally twice daily for 10 days
- Age >35 years (likely enteric organisms): Ofloxacin 300 mg orally twice daily or Levofloxacin 500 mg orally once daily for 10 days
- Supportive measures: rest, scrotal elevation, NSAIDs 1
Remember that clinical improvement should occur within 3 days of starting treatment for epididymitis. If improvement does not occur, reevaluation of both diagnosis and therapy is necessary 1.