What is the best course of action for a 16-year-old male patient who experienced testicular trauma 8 days ago, with initial resolution of pain, but now has recurrent pain, worse on the left side, after playing soccer, currently managed with Advil (ibuprofen)?

Management of Testicular Trauma in a 16-Year-Old Male

The 16-year-old male with recurrent testicular pain following trauma requires urgent scrotal ultrasound with Doppler to rule out testicular torsion, rupture, or other serious complications requiring surgical intervention.

SOAP Note Development Questions

Subjective

• When exactly did the injury occur? (8 days ago during soccer)
• Describe the mechanism of injury (direct blow with cleats)
• Pain characteristics:
  • Initial severity (1-10 scale)
  • Duration of initial pain
  • Complete resolution between episodes?
  • Current pain (5/10 after Advil)
  • Pain radiation to abdomen or groin?
  • What activities worsen the pain besides walking?
  • Does elevation of scrotum relieve pain (Prehn's sign)?
• Associated symptoms:
  • Nausea/vomiting? (None reported)
  • Fever or chills?
  • Urinary symptoms (dysuria, hematuria, frequency)?
  • Any discharge from penis?
  • Sexual activity history (relevant for STI consideration)?

Objective

• Vital signs (temperature, heart rate, blood pressure)
• General appearance (distress level)
• Abdominal examination:
  • Tenderness in lower abdomen or inguinal regions?
  • Presence of hernia?
• Genital examination:
  • Testicular position (high-riding or normal)
  • Presence of swelling, erythema, or bruising
  • Tenderness to palpation (localized vs. diffuse)
  • Cremasteric reflex present or absent?
  • Transillumination findings
  • Epididymal tenderness or swelling

Assessment

• Differential diagnosis to consider:
  1. Delayed testicular contusion/hematoma
  2. Testicular torsion (intermittent or acute)
  3. Epididymitis (traumatic or infectious)
  4. Testicular rupture
  5. Hydrocele secondary to trauma
  6. Testicular appendage torsion

Plan

1. Diagnostic studies:

   • Scrotal ultrasound with Doppler (most critical test) 1, 2
   • Urinalysis to evaluate for infection or hematuria
   • Consider CBC if infection suspected

2. Treatment options based on findings:

   • If normal ultrasound with contusion only: NSAIDs, scrotal support, rest
   • If torsion: immediate urological consultation for surgical exploration
   • If rupture: surgical repair
   • If epididymitis: appropriate antibiotics if infectious etiology suspected

3. Pain management:

   • Continue NSAIDs (ibuprofen has shown beneficial effects in testicular injury) 3
   • Scrotal elevation and support
   • Ice packs for acute pain

4. Follow-up:

   • Timing based on diagnosis (24-48 hours for conservative management)
   • Warning signs requiring immediate return (severe pain, vomiting, fever)

Key Clinical Considerations

Urgent vs. Non-urgent Management

The recurrence of pain 8 days after initial trauma is concerning and requires prompt evaluation. The American College of Radiology strongly recommends ultrasound with Doppler as the initial imaging study for acute scrotal pain to differentiate between conditions requiring surgical intervention versus those that can be managed conservatively 1, 2.

Diagnostic Approach

The key diagnostic features to differentiate between testicular torsion and other conditions include:

• Onset (sudden vs. gradual)
• Pain relief with elevation (Prehn's sign)
• Cremasteric reflex (absent in torsion)
• Testicular position (high-riding in torsion)
• Doppler ultrasound findings (decreased/absent blood flow in torsion vs. increased in epididymitis) 4

Treatment Considerations

Early exploration is recommended for cases with significant hematocele or suspected testicular rupture, with a reported testicular salvage rate of 86% 5. For uncomplicated contusions, conservative management with NSAIDs (particularly ibuprofen, which has shown superior results in animal models of testicular injury), scrotal support, and rest is appropriate 3.

Common Pitfalls

1. Delaying imaging in a patient with recurrent pain after trauma
2. Failing to consider intermittent testicular torsion in the differential diagnosis
3. Inadequate pain management leading to delayed recovery
4. Missing signs of testicular rupture which requires surgical intervention

Ultrasound findings will guide definitive management, with surgical exploration indicated for testicular rupture or torsion, while contusion or minor injury can be managed conservatively with close follow-up.