What is the differential diagnosis and workup for testicular pain in an adult male with congestive heart failure?

Testicular Pain in an Adult Male with Congestive Heart Failure: Differential and Workup

Testicular pain in a patient with congestive heart failure requires immediate evaluation for testicular torsion as the primary life-of-testicle emergency, followed by assessment for other acute scrotal pathology, while recognizing that the heart failure itself does not directly cause testicular pain and should not delay urologic evaluation.

Immediate Clinical Assessment

The most critical consideration is testicular torsion, which is a surgical emergency requiring intervention within 4-8 hours to prevent permanent ischemic damage and orchiectomy 1. While testicular torsion has a bimodal distribution (first year of life and ages 12-18), it absolutely occurs in adults and must be excluded in all patients presenting with acute scrotal pain 2.

Key Physical Examination Findings

Perform focused testicular examination looking for:

• High-riding testicle with horizontal orientation - classic for torsion 3
• Absent cremasteric reflex - though its presence does not exclude torsion 1, 2
• Acute unilateral severe scrotal pain - most common presenting symptom 1, 2
• Nausea and vomiting - frequently present with torsion 4, 1
• Red, swollen scrotum - may be present 4

Critical pitfall: The presence of a cremasteric reflex is NOT a reliable indicator to exclude testicular torsion 2. Do not be falsely reassured by its presence.

Differential Diagnosis

Primary Urologic Causes (Unrelated to Heart Failure)

• Testicular torsion - surgical emergency 4, 1, 2
• Epididymitis - can be differentiated by scrotal elevation (Prehn's sign), though imaging is more reliable 4
• Strangulated inguinal hernia - may present with testicular pain 4
• Traumatic hematoma - obtain history of trauma 4
• Testicular tumor or fracture - less common but important 4
• Hydrocele, idiopathic scrotal edema - typically less acute 5

Heart Failure-Related Considerations

Important clinical context: The congestive heart failure itself does not cause testicular pain. However, consider:

• Scrotal edema from volume overload - this causes discomfort but not acute severe pain, and would be bilateral 6
• Medication-related effects - review the patient's heart failure medications, though none typically cause acute testicular pain 7, 6

Diagnostic Workup

Immediate Imaging (Do Not Delay)

If testicular torsion is suspected clinically, proceed immediately to surgical exploration without waiting for imaging 1. However, when diagnosis is uncertain:

• Point-of-care or formal Doppler ultrasound - most helpful for confirming diagnosis, assessing testicular blood flow 4, 3
• Critical limitation: A normal ultrasound does NOT exclude testicular torsion 2
• Radionuclide testicular scintigraphy with 99mTc - helpful when past the acute phase (>12 hours) 4

Clinical Decision Support

The TWIST score may assist with clinical decision-making in patients with acute testicular pain, but should not be used in isolation and should not delay consultation 2.

Heart Failure Assessment (Secondary Priority)

While evaluating testicular pain, assess the patient's heart failure status:

• Volume status examination - jugular venous distension, peripheral edema, pulmonary rales 6
• Daily weight monitoring - if patient is admitted 6
• Renal function and electrolytes - especially if diuretic therapy is ongoing 6

Do not assume testicular pain is related to heart failure edema without excluding surgical emergencies first.

Management Algorithm

Step 1: Immediate Triage

• If severe acute unilateral testicular pain with high-riding testicle and absent cremasteric reflex → immediate urology consultation for surgical exploration 1, 2
• Do not delay for imaging if clinical suspicion is high 1

Step 2: If Diagnosis Uncertain

• Obtain Doppler ultrasound while simultaneously consulting urology 4, 3
• Remember: testicles can torse and detorse, causing intermittent symptoms 5

Step 3: While Awaiting Definitive Management

• Manual detorsion can be attempted in the emergency department while awaiting transfer or surgical consultation 3, 2
• Point-of-care ultrasound can guide manual detorsion and verify return of blood flow 3
• Provide symptomatic pain management 2

Step 4: Heart Failure Management Continues Concurrently

• Continue monitoring volume status and diuretic therapy as indicated 6
• Ensure renal function and electrolytes are monitored if patient requires surgery 6

Critical Pitfalls to Avoid

• Never attribute acute testicular pain to heart failure edema alone - this can lead to missed testicular torsion and testicular loss 1, 2
• Do not delay urology consultation - outcomes are time-sensitive with a 4-8 hour window for salvage 1, 2
• Do not rely on normal ultrasound to exclude torsion - if clinical suspicion remains high, proceed to surgical exploration 2
• Do not be falsely reassured by presence of cremasteric reflex - it is not reliable for excluding torsion 2

Prognosis

Long-term prognosis for a functional, non-atrophied testicle is directly related to time from symptom onset to surgical intervention 4. The orchiectomy rate in boys undergoing surgery for testicular torsion is 42%, emphasizing the importance of rapid diagnosis and treatment 1.