What is the diagnosis and treatment for intermittent testicular pain, worsening over time, with accompanying urinary frequency and pain with ejaculation?

Differential Diagnosis and Management of Testicular Pain with Urinary Symptoms

Most Likely Diagnosis

This clinical presentation most strongly suggests epididymitis, given the gradual onset over 2 weeks, bilateral involvement, urinary frequency, and pain with ejaculation. 1

Key Differential Diagnoses

Epididymitis/Epididymo-orchitis (Most Likely)

• Gradual onset of pain over days to weeks is the hallmark distinguishing feature from testicular torsion 1
• Urinary frequency and dysuria commonly accompany epididymitis 2
• Pain with ejaculation is characteristic of epididymo-orchitis 2
• Bilateral involvement can occur, though unilateral is more common 1
• May have abnormal urinalysis, though normal urinalysis does not exclude the diagnosis 1

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• Pain in the perineum, suprapubic region, testicles, or tip of penis that is exacerbated by urination or ejaculation 2
• Voiding symptoms including urinary frequency and sense of incomplete bladder emptying 2
• The clinical characteristics overlap significantly with IC/BPS, and men with bladder-related pain, pressure, and urinary frequency should be considered for this diagnosis 2
• Some patients meet criteria for both conditions and may benefit from combined treatment approaches 2

Intermittent Testicular Torsion (Less Likely but Critical to Exclude)

• Characterized by acute intermittent sharp testicular pain and scrotal swelling with long symptom-free intervals 3
• Physical findings may include horizontal or very mobile testes, anteriorly located epididymis, or bulky spermatic cord 3
• Testes can torse and detorse spontaneously, making diagnosis confounding 4
• The 2-week duration with worsening pain makes complete torsion less likely, but intermittent torsion remains possible 3, 5

Critical Immediate Actions

Urgent Doppler Ultrasound Indications

Order urgent Duplex Doppler ultrasound if:

• Pain becomes sudden or severe 1
• Physical exam reveals horizontal testicular lie, very mobile testes, or testicular size discrepancy 3, 5
• Any concern for torsion exists, as false-negative Doppler can occur with partial torsion or spontaneous detorsion 1

Red Flags Requiring Immediate Urological Consultation

• Abrupt onset of severe pain (testicular torsion requires surgical intervention within 6-8 hours) 1
• Negative Prehn sign (pain not relieved with testicular elevation) 1
• Normal urinalysis with severe acute pain (does not exclude torsion) 1

Diagnostic Workup

Essential Testing

• Urinalysis and urine culture to evaluate for infection 1
• Duplex Doppler ultrasound if any concern for torsion or to confirm epididymitis (will show increased blood flow in epididymitis vs. decreased flow in torsion) 1
• Urethral swab or first-void urine for Chlamydia trachomatis and Neisseria gonorrhoeae if sexually active 6

Physical Examination Findings to Assess

• Testicular lie (horizontal vs. vertical orientation) 3, 5
• Testicular mobility and size symmetry 3, 5
• Epididymal tenderness and swelling 1
• Prehn sign (pain relief with testicular elevation suggests epididymitis) 1
• Cremasteric reflex (absent in torsion, present in epididymitis) 1

Treatment Approach

For Epididymitis (Most Likely Diagnosis)

Empiric antibiotic therapy should be initiated immediately while awaiting culture results:

If Sexually Transmitted Infection Suspected (Age <35, sexually active)

• Ceftriaxone 250-500 mg IM once 7
• PLUS Doxycycline 100 mg PO twice daily for 10 days 6
• This covers both Neisseria gonorrhoeae and Chlamydia trachomatis 6, 7

If Enteric Organisms Suspected (Age >35, recent urinary instrumentation)

• Doxycycline 100 mg PO twice daily for 10 days 6
• Alternative: fluoroquinolone if local resistance patterns allow 6

Supportive Measures

• Scrotal elevation and support 1
• NSAIDs for pain control 1
• Bed rest until inflammation subsides 1
• Avoid sexual activity until treatment complete 6

For Chronic Prostatitis/CPPS Component

• If symptoms persist beyond acute treatment, consider IC/BPS therapies as empiric strategies have shown improvement in some CP/CPPS patients 2
• Alpha-blockers and anti-inflammatory agents may provide benefit 2

Follow-Up and Monitoring

Short-Term (48-72 hours)

• Reassess for symptom improvement - if pain worsens or fails to improve, reconsider torsion or other diagnoses 1
• Ensure compliance with full antibiotic course 6

Long-Term Considerations

• If intermittent pain persists after treatment, bilateral testicular fixation should be considered to prevent testicular loss from intermittent torsion 5
• Children and adolescents with recurrent testicular pain and positive clinical findings (horizontal testis, size discrepancy) have high incidence of "bell clapper" deformity requiring surgical fixation 5

Critical Pitfalls to Avoid

• Do not dismiss the possibility of intermittent torsion based on bilateral symptoms or gradual onset alone - torsion can present atypically 3, 4
• Normal urinalysis does not exclude either epididymitis or testicular torsion 1
• Significant overlap exists in clinical presentation between different causes of scrotal pain - maintain high index of suspicion 1
• Do not delay imaging if any clinical suspicion for torsion exists - testicular viability is compromised after 6-8 hours 1