Immediate Evaluation for Testicular Torsion and Epididymitis
A 50-year-old man with 3 weeks of intermittent testicular pain requires urgent Doppler ultrasound to exclude intermittent testicular torsion, followed by evaluation for epididymitis or chronic orchialgia, as intermittent torsion can present with recurrent pain episodes that spontaneously resolve but risk future testicular infarction. 1, 2
Initial Diagnostic Approach
Critical Time-Sensitive Considerations
While testicular torsion is rare over age 35, intermittent testicular torsion (ITT) presents with recurrent episodes of severe pain with rapid onset and spontaneous resolution, and this pattern warrants surgical consideration regardless of age 1, 2. The intermittent nature of this patient's pain over 3 weeks makes ITT a diagnostic possibility that cannot be dismissed based on age alone.
Key distinguishing features to assess immediately:
- Pain characteristics: Abrupt onset with spontaneous resolution suggests intermittent torsion, while gradual onset over days suggests epididymitis 1, 3
- Severity and timing: Severe pain episodes with rapid resolution are highly characteristic of ITT 2
- Associated symptoms: Nausea/vomiting occurs in 25% of ITT cases; urinary frequency and dysuria suggest epididymitis 3, 2
- Physical examination findings: Horizontal lie of the testis is significantly associated with bell-clapper deformity and ITT risk 2, 4
Mandatory Diagnostic Testing
Obtain urgent Doppler ultrasound of the scrotum even with intermittent symptoms, as false-negative results can occur with partial torsion or spontaneous detorsion 1, 3. The ultrasound should include:
- Grayscale examination to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
- Color Doppler assessment of testicular perfusion (96-100% sensitivity) 1
- Comparison with the contralateral asymptomatic testicle as internal control 1
Obtain urinalysis and urine culture to evaluate for infection, though normal urinalysis does not exclude either epididymitis or torsion 1, 3.
Age-Specific Differential Diagnosis
At age 50, epididymitis is overwhelmingly the most common cause of testicular pain, representing approximately 600,000 cases annually in U.S. adults 1. However, the intermittent pattern over 3 weeks requires consideration of:
Primary Considerations:
Epididymitis/epididymo-orchitis: Gradual onset, may have urinary symptoms, enlarged epididymis with increased blood flow on Doppler 1, 3
Intermittent testicular torsion: Recurrent severe pain with rapid resolution, horizontal testicular lie, bell-clapper deformity at surgery 2, 4
Chronic orchialgia: Defined as ≥3 months of chronic or intermittent pain, but this patient is at 3 weeks 5, 6
Additional Considerations:
- Testicular mass/tumor: A painless solid testicular mass is pathognomonic, though patients may present with discomfort or swelling 7
- Varicocele, spermatocele: Easily recognized reversible causes 5
- Segmental testicular infarction: Wedge-shaped avascular area on ultrasound 1
Management Algorithm
If Doppler Shows Decreased Flow or Whirlpool Sign:
Immediate urological consultation and surgical exploration is indicated, as ITT patients have bell-clapper deformity in 100% of cases and bilateral testicular fixation results in complete symptom resolution in 97% 2, 4. Surgery prevents future testicular infarction and is associated with low morbidity 2.
If Doppler Shows Increased Epididymal Flow:
Initiate empiric antibiotic therapy immediately while awaiting culture results 3. Treatment includes:
- Appropriate antibiotics based on age and risk factors
- Scrotal elevation and support
- NSAIDs for pain control
- Bed rest until inflammation subsides 3
Reassess within 48-72 hours: If pain worsens or fails to improve, reconsider torsion or other diagnoses 3.
If Doppler is Normal but Intermittent Pain Pattern Persists:
Consider surgical consultation for bilateral testicular fixation, as clinical examination showing horizontal testicular lie is highly correlated with bell-clapper deformity at surgical exploration 2, 4. All patients with ITT and positive clinical findings should undergo bilateral fixation to improve testicular salvage rate and prevent testicular atrophy 4.
Critical Pitfalls to Avoid
- Do not dismiss torsion based on age alone: While rare over 35, ITT can occur at any age and has serious implications for testicular viability 1, 2
- Do not rely on normal urinalysis: Normal results do not exclude either epididymitis or torsion 1, 3
- Do not delay imaging: Significant overlap exists in clinical presentation between different causes, and false-negative Doppler can occur with partial torsion 1, 3
- Do not give prolonged antibiotic trial without imaging: A trial of antibiotics may be given for suspected epididymitis, but persistent tenderness, swelling, or any palpable abnormality warrants further evaluation 7
If Symptoms Persist Beyond 3 Months
Should symptoms continue to 3 months despite treatment, the diagnosis becomes chronic orchialgia, and management options include 5, 6: