From the Guidelines
For a 50-year-old male presenting with testicular pain in the ED, the next step in management should begin with a focused history and physical examination, including scrotal examination to assess for tenderness, swelling, and testicular position, followed by urgent ultrasound of the scrotum with Doppler flow to rule out testicular torsion, which is a surgical emergency, as recommended by the American College of Radiology 1. The patient's age and presentation suggest that epididymitis is a more likely cause of acute scrotal pain than testicular torsion, which is rare in patients over 35 years of age 1. However, given the potential for significant morbidity and mortality associated with delayed treatment of testicular torsion, it is essential to rule out this condition promptly. Key components of the initial evaluation include:
- Focused history and physical examination, including scrotal examination
- Urgent ultrasound of the scrotum with Doppler flow to rule out testicular torsion
- Laboratory tests, such as urinalysis, complete blood count, and possibly testicular tumor markers (AFP, beta-hCG, LDH) if mass is suspected
- Pain management with NSAIDs, such as ibuprofen 600mg orally every 6 hours If torsion is suspected based on physical exam or ultrasound findings, immediate urology consultation is necessary for potential surgical intervention 1. For epididymitis, treatment includes antibiotics, such as ceftriaxone 250mg IM once plus doxycycline 100mg orally twice daily for 10 days, as well as scrotal support and ice packs for symptomatic relief. The urgency of management is critical, as delayed treatment of torsion beyond 6 hours can lead to testicular loss, while prompt treatment of infections prevents complications.
From the Research
Next Steps in Management
The next step in management for a 50-year-old patient presenting to the Emergency Department (ED) with testicular pain involves a thorough evaluation to determine the underlying cause of the pain. The differential diagnosis for acute scrotal pain includes testicular torsion, epididymitis, and other conditions such as strangulated inguinal hernia, traumatic hematoma, testicular tumor, or testicular fracture 2.
Diagnostic Approach
A physical examination, including scrotal elevation, can be helpful in differentiating between epididymitis and testicular torsion 2. However, emergent imaging with Doppler ultrasound is the most helpful in confirming the diagnosis of testicular torsion 2, 3, 4. The ultrasound findings for testicular torsion include an enlarged testis with inhomogeneous echotexture, reduced or absent intratesticular vessels on color Doppler, and decreased flow velocities on spectral Doppler 3.
Management of Testicular Torsion
If testicular torsion is suspected, the patient should undergo immediate exploratory surgery without diagnostic studies 5. Manual reduction of the torsion can be attempted, but many patients will require surgical exploration by a urologist 2. The sooner the torsion is diagnosed and treated, the better the long-term prognosis for a functional, nonatrophied testicle 2.
Management of Epididymitis
If the diagnosis is epididymitis, the treatment will depend on the patient's age and the likely causative organisms 6. For men older than 35 years, epididymitis is usually caused by enteric bacteria, and treatment with levofloxacin or ofloxacin alone is sufficient 6.
Importance of Prompt Diagnosis
Prompt diagnosis and management of testicular torsion are essential to prevent complications such as testicular infarction, necrosis, and sub/infertility 4. Any delay in diagnosis and treatment can result in significant morbidity and potential medicolegal challenges 4, 5.