Treatment Plan for 18-Year-Old Male with Testicular Pain
Testicular torsion must be immediately excluded through urgent urological consultation and surgical exploration if clinically suspected, as testicular viability depends on intervention within 6-8 hours of symptom onset. 1
Immediate Assessment and Risk Stratification
Critical Clinical Features to Evaluate
- Onset and severity of pain: Abrupt, severe unilateral scrotal pain strongly suggests torsion, while gradual onset suggests epididymitis 1
- Duration of symptoms: Document exact time of pain onset, as the 6-8 hour window is critical for testicular salvage 1, 2
- Associated symptoms: Nausea and vomiting are common with torsion 2, 3
- Physical examination findings:
Age-Specific Considerations
At 18 years old, this patient falls within the high-risk postpubertal peak for testicular torsion, which has a bimodal distribution affecting neonates and adolescents most commonly 1, 5
Diagnostic Algorithm
High Clinical Suspicion for Torsion
If clinical features suggest torsion (sudden severe pain, negative Prehn sign, absent cremasteric reflex), proceed directly to immediate urological consultation and surgical exploration WITHOUT waiting for imaging studies. 1, 2
Intermediate Clinical Suspicion
- Obtain urgent Duplex Doppler ultrasound of the scrotum, which should include 1:
- Grayscale examination for testicular homogeneity and the "whirlpool sign" (96% sensitivity)
- Color Doppler assessment of testicular perfusion (96-100% sensitivity)
- Power Doppler evaluation
- Use contralateral testicle as internal control
Critical caveat: A normal ultrasound does NOT exclude torsion, as false-negatives occur with partial torsion or spontaneous detorsion 1, 3. If clinical suspicion remains high despite normal imaging, proceed to surgical exploration.
Definitive Treatment
Surgical Management
Immediate urological consultation and prompt surgical exploration is the definitive treatment for testicular torsion. 1
- Surgical detorsion and bilateral orchiopexy should occur within 6-8 hours of symptom onset to prevent permanent ischemic damage 1, 5
- Surgical outcomes are significantly better when surgery occurs within 12 hours 1
- Delay beyond this window results in orchiectomy rates of 42% in affected patients 2
Emergency Department Temporizing Measures
While awaiting surgical consultation 3:
- Provide symptomatic pain management with analgesics
- Consider manual detorsion attempt (though this should not delay surgical consultation)
- Keep patient NPO in preparation for surgery
Post-Operative Care
Following surgical detorsion 1:
- Bed rest until inflammation subsides
- Scrotal elevation
- Analgesics for pain control
Differential Diagnosis Considerations
The three most common causes of acute scrotal pain in this age group are 1:
- Testicular torsion (surgical emergency requiring 6-8 hour intervention)
- Epididymitis/epididymo-orchitis (most common in adults >25 years, but can occur in adolescents; evaluate with urinalysis and ultrasound)
- Torsion of testicular appendage (more common in prepubertal boys; "blue dot sign" pathognomonic but only present in 21% of cases)
When Torsion is Ruled Out
If imaging and clinical evaluation definitively exclude torsion, consider 1:
- Urinalysis and urine culture for infectious causes
- STI testing if sexually active
- Treatment for epididymitis with appropriate antibiotics if indicated
Key Clinical Pitfalls to Avoid
- Never delay surgical consultation to obtain imaging if clinical suspicion is high 1, 2
- Do not rely on cremasteric reflex alone as its presence does not exclude torsion 3
- Do not be falsely reassured by normal ultrasound if clinical suspicion remains high 1, 3
- Consider intermittent torsion in patients with recurrent episodes of severe pain with spontaneous resolution, as these patients require prophylactic bilateral orchiopexy 4