What is the appropriate workup and treatment for a patient presenting with testicular pain?

Workup for Testicular Pain

Immediate Clinical Assessment

For any patient presenting with acute testicular pain, testicular torsion must be excluded first, as this is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular loss. 1, 2

Key Clinical Features to Assess

• Onset and timing of pain: Testicular torsion presents with abrupt, severe unilateral scrotal pain, while epididymitis has gradual onset 1, 2
• Age of patient: Torsion has bimodal distribution (neonates and postpubertal boys aged 12-18 years); epididymitis is most common in adults >25 years 1, 2
• Associated symptoms: Nausea and vomiting are common with torsion 3, 4, 5
• Cremasteric reflex: Absent ipsilateral cremasteric reflex is the most accurate sign of testicular torsion 5, 6
• Prehn sign: Negative Prehn sign (pain not relieved with testicular elevation) suggests torsion over epididymitis 2
• Urinalysis: Normal urinalysis does not exclude epididymitis but supports torsion diagnosis 1

Risk Stratification Using TWIST Score (Pediatric Patients 3 months-18 years)

The TWIST score helps guide management decisions 1, 2:

• High TWIST scores (≥6): Proceed directly to immediate urological consultation and surgical exploration without imaging 1
• Intermediate TWIST scores (1-5): Obtain urgent Duplex Doppler ultrasound 1, 2
• Low TWIST scores: May benefit from Doppler ultrasound to confirm alternative diagnosis 1

Imaging Protocol

First-Line Imaging: Duplex Doppler Ultrasound of Scrotum

Duplex Doppler ultrasound is the established first-line imaging modality for acute scrotal pain and should include grayscale, color Doppler, and power Doppler evaluation of both testicles. 1, 2

Grayscale Ultrasound Findings

• "Whirlpool sign": Spiral twist of spermatic cord (96% sensitivity, 99% specificity for torsion) 1, 2
• Testicular appearance: Enlarged, heterogeneous, hypoechoic testis suggests torsion 1
• Associated findings: Ipsilateral hydrocele, scrotal wall thickening 1

Doppler Ultrasound Findings

• Testicular torsion: Decreased or absent blood flow to affected testicle (sensitivity 69-96.8%, specificity 87-100%) 1, 2
• Partial torsion: Variable amplitude of spectral Doppler waveform, reversed diastolic flow, monophasic waveform, or tardus-parvus morphology 1
• Epididymitis/epididymo-orchitis: Enlarged hypoechoic epididymis with increased blood flow (nearly 100% sensitivity for inflammation) 1
• Appendage torsion: Wedge-shaped avascular focal area, though "blue dot sign" on physical exam is pathognomonic but only seen in 21% of cases 1, 2

Critical Technical Points

• Use contralateral asymptomatic testicle as internal control 1, 2
• Perform spectral Doppler analysis in upper, mid, and lower poles of each testicle 1
• Power Doppler is more sensitive than color Doppler for low-flow states, especially in prepubertal testes 1

Important Caveats About Imaging

• False-negative Doppler can occur with partial torsion or spontaneous detorsion 1, 2
• False-positive Doppler can occur in infants/young boys with normally reduced intratesticular flow 1
• Normal ultrasound does NOT exclude testicular torsion 4
• If clinical suspicion for torsion is high, do NOT delay surgical exploration to obtain imaging 5, 6

Management Algorithm

If Testicular Torsion is Suspected or Confirmed

Immediate urological consultation and prompt surgical exploration is the definitive treatment and should not be delayed. 2, 4, 5

• Time-sensitive intervention: Surgical detorsion within 6-8 hours of symptom onset is essential; testicular salvage rate decreases significantly after 6 hours 1, 2, 5, 6
• Manual detorsion: Can be attempted in ED while awaiting surgery by external rotation of testis (typically "open book" lateral-to-medial rotation), but restoration of blood flow must be confirmed 4, 6
• Bilateral orchiopexy: Performed during surgery to prevent recurrence and treat contralateral bell-clapper deformity 6, 7

If Epididymitis/Epididymo-orchitis is Diagnosed

• Most common cause in adults >25 years and accounts for approximately 600,000 cases annually in the US 1
• Treatment: Appropriate antibiotics based on age and risk factors, bed rest, scrotal elevation, and analgesics 2
• Caution: Diagnosis should be made with caution in prepubertal males, as epididymitis is much less common in this age group 6

If Torsion of Testicular Appendage is Diagnosed

• Most common cause of acute scrotal pain in prepubertal boys 1, 2
• Management: Conservative management with NSAIDs and scrotal support; surgical exploration is not mandatory but hastens recovery 6

Common Pitfalls to Avoid

• Never delay surgical consultation for imaging if clinical suspicion for torsion is high 5, 6
• Do not rely on presence or absence of cremasteric reflex alone, though its absence is highly suggestive 4
• Do not assume normal urinalysis excludes epididymitis 1
• Do not trust a normal ultrasound to definitively rule out torsion in high-risk patients 4
• Remember that torsion can occur in adults, though rare after age 35 1