What is the appropriate workup for testicular pain (orchialgia)?

From the Guidelines

The workup for testicular pain should begin with a thorough history and physical examination, focusing on onset, duration, severity, and associated symptoms, followed by scrotal ultrasound with color Doppler as the gold standard imaging modality to differentiate between torsion, epididymitis, orchitis, varicocele, hydrocele, or tumors 1. The initial evaluation includes scrotal examination to assess for tenderness, swelling, masses, and cremasteric reflex. Urgent conditions like testicular torsion require immediate urological consultation, as surgical intervention within 6 hours maximizes testicular salvage 1. Laboratory tests should include urinalysis, complete blood count, and sexually transmitted infection screening if indicated. For epididymitis, treatment typically involves antibiotics such as doxycycline 100mg twice daily for 10 days for sexually transmitted causes, or fluoroquinolones like ciprofloxacin 500mg twice daily for 10 days for enteric pathogens 1. Pain management includes NSAIDs like ibuprofen 600mg every 6 hours, scrotal elevation, and ice packs. Some key points to consider in the workup and management of testicular pain include:

• The importance of prompt recognition and treatment of testicular torsion to prevent testicular loss 1
• The use of scrotal ultrasound with color Doppler to differentiate between torsion, epididymitis, orchitis, varicocele, hydrocele, or tumors 1
• The treatment of epididymitis with antibiotics and pain management with NSAIDs, scrotal elevation, and ice packs 1
• The need for follow-up evaluation to ensure resolution of symptoms and exclude underlying pathology. It is essential to prioritize the most recent and highest quality study, which in this case is the 2024 update on acute onset of scrotal pain without trauma or antecedent mass 1.

From the Research

Testicular Pain Workup

• The workup for testicular pain involves a thorough history and physical examination to determine the underlying cause of the pain, which can range from non-urgent inflammatory conditions like epididymo-orchitis to testicular torsion, a surgical emergency 2, 3, 4, 5, 6.
• Key features that can raise the index of suspicion for a particular diagnosis include the presence of a swollen, tender testis with swelling of the epididymis, and the absence of a cremasteric reflex in cases of testicular torsion 3, 5.
• Imaging studies such as testicular ultrasonography can play a vital role in the prompt diagnosis of testicular torsion, but should not delay immediate surgical exploration if history and physical examination suggest torsion 5, 6.
• A hand-held Doppler (HHD) examination can be used as a first-line triaging tool to rule out testicular torsion in patients presenting with acute testicular pain, with a specificity of 97.8% 2.
• Patients with testicular pain should be presumed to have testicular torsion until proven otherwise, as this condition carries a high degree of morbidity, including testicular necrosis, infarction, or atrophy with concomitant infertility 4, 5.
• Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum, with a four- to eight-hour window before permanent ischemic damage occurs 5, 6.