What is the initial workup and management for a patient presenting with testicular pain?

Workup for Testicular Pain

For any patient presenting with testicular pain, immediately assess for testicular torsion as this is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss, and when clinical suspicion exists, proceed directly to urgent Duplex Doppler ultrasound and simultaneous urology consultation without delay. 1

Initial Clinical Assessment

Critical Historical Features to Obtain

• Onset and timing of pain - Abrupt, sudden onset of severe scrotal pain strongly suggests testicular torsion, while gradual onset over hours to days is more consistent with epididymitis 1
• Duration of symptoms - Document exact time of pain onset, as testicular viability is compromised after 6-8 hours and surgical outcomes worsen significantly after 12 hours 1
• Associated symptoms - Nausea and vomiting commonly accompany testicular torsion 2
• Age of patient - Torsion has a bimodal distribution with peaks in neonates and postpubertal boys (12-18 years), while epididymitis is more common in adults over 25 years 1

Physical Examination Findings

• Prehn sign - A negative Prehn sign (pain NOT relieved with testicular elevation) suggests torsion 1
• Cremasteric reflex - While often discussed, its presence or absence is NOT a reliable indicator and should not be used to rule out torsion 2
• "Blue dot sign" - Pathognomonic for appendage torsion but only visible in 21% of cases 1

Risk Stratification Tool

• TWIST score (Testicular Workup for Ischemia and Suspected Torsion) can assist with clinical decision-making and has high positive predictive value 1
• For intermediate clinical suspicion (TWIST score 1-5), proceed immediately to urgent Duplex Doppler ultrasound 1
• Critical caveat: The TWIST score should NOT be used in isolation to exclude torsion 2

Diagnostic Testing Algorithm

Laboratory Studies

• Urinalysis - Obtain in all patients, but recognize that normal urinalysis does NOT exclude either testicular torsion or epididymitis 1
• Abnormal urinalysis may support epididymitis diagnosis but is not definitive 1

Imaging Studies

Duplex Doppler ultrasound is the first-line imaging modality and should include three components: 1

1. Grayscale examination - Assesses testicular homogeneity and identifies the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
2. Color Doppler assessment - Evaluates testicular perfusion with sensitivity of 96-100% 1
3. Power Doppler - Provides additional perfusion information 1

Key Ultrasound Findings by Diagnosis

Testicular torsion: 1

• Decreased or absent blood flow to affected testicle
• "Whirlpool sign" (most specific finding)
• Enlarged heterogeneous testis appearing hypoechoic
• Ipsilateral hydrocele
• Scrotal skin thickening

Critical imaging pitfalls: 1, 3

• False-negative Doppler evaluations occur with partial torsion or spontaneous detorsion
• Overall sensitivity of ultrasound ranges from 69% to 96.8%, meaning up to 31% of cases may be missed
• Always use the contralateral asymptomatic testicle as an internal control
• A normal ultrasound examination CANNOT exclude testicular torsion 2, 3

Management Based on Diagnosis

If Testicular Torsion is Suspected or Confirmed

Immediate actions: 1

• Do NOT delay urology consultation - Contact urology immediately upon clinical suspicion, even before imaging
• Proceed to emergent surgical exploration and detorsion
• Manual detorsion can be attempted in the emergency department while awaiting transfer or surgical consultation 2

Age-Stratified Differential Diagnosis

Prepubertal boys: 1

• Torsion of testicular appendage is most common cause
• Testicular torsion remains in differential

Adolescents (12-18 years): 1

• Testicular torsion (peak incidence: 2.9-3.8 per 100,000 boys under 18 years annually)
• Epididymitis/epididymo-orchitis
• Torsion of testicular appendage

Adults over 25 years: 1

• Epididymitis/epididymo-orchitis is overwhelmingly most common (approximately 600,000 cases annually in United States)
• Testicular torsion is rare in patients over 35 years

Adults over 35 years: 1

• Testicular torsion becomes exceedingly rare
• Consider epididymitis, segmental testicular infarction, acute idiopathic scrotal edema, or tumor

Additional Differential Considerations

• Segmental testicular infarction - Classic wedge-shaped avascular area on ultrasound 1
• Acute idiopathic scrotal edema - Rare, self-limiting, usually painless with marked scrotal wall thickening; diagnosis of exclusion 1
• Chronic testicular pain - Defined as at least 3 months of chronic or intermittent pain; requires different evaluation pathway 4, 5

Critical Clinical Pitfalls to Avoid

• Never rely on cremasteric reflex presence to exclude torsion 2
• Never accept normal ultrasound as definitive exclusion of torsion when clinical suspicion is high - Proceed to surgical exploration 2, 3
• Never delay urology consultation to obtain imaging - These should occur simultaneously 1
• Recognize significant overlap in clinical presentations between different causes of acute scrotal pain, making diagnosis challenging 1
• Remember partial torsion presents with less severe symptoms but still requires surgical intervention 1
• Do not assume spontaneous detorsion means no intervention needed - These patients still require urgent urology evaluation as retorsion is likely 6