What is the best course of action for a transgender male in their 60's, with a history of hormone replacement therapy (HRT), vasectomy, and a small hydrocele on the left testicle, experiencing testicular pain with ejaculation and scrotal pain on the right testicle?

Evaluation and Management of Testicular Pain with Ejaculation in a Transgender Male

This patient requires urgent scrotal Duplex Doppler ultrasound to evaluate the right testicular pain and reassess the left hydrocele, with particular attention to ruling out testicular malignancy, post-vasectomy pain syndrome, and epididymo-orchitis. 1

Immediate Diagnostic Workup

Primary Imaging

• Duplex Doppler ultrasound of the scrotum is the essential first-line imaging modality for evaluating acute or chronic scrotal pain without trauma 1
• The examination must include:
  • Grayscale assessment of both testes for masses, heterogeneity, or structural abnormalities 1
  • Color and Power Doppler evaluation of testicular perfusion and vascularity 1
  • Detailed evaluation of the epididymis for enlargement or increased vascularity 1
  • Reassessment of the known left hydrocele with attention to any solid components or septations 2, 3

Critical Diagnostic Considerations

The small left hydrocele warrants careful scrutiny, as hydroceles can mask underlying testicular tumors, particularly in men of reproductive age. 4, 3 While hydroceles are typically benign, any "complex" appearance with septations or solid components should raise suspicion for malignancy 3. The ultrasound must definitively characterize whether this is a simple or complex hydrocele 2.

Differential Diagnosis by Priority

1. Post-Vasectomy Pain Syndrome (Right Testicle)

• Chronic scrotal pain following vasectomy is well-documented and can persist for years 5
• Pain with ejaculation is a characteristic feature of this syndrome 5
• The right-sided pain correlating with the vasectomy history makes this the leading diagnosis for that side 5

2. Chronic Epididymitis/Epididymo-orchitis

• In adults, epididymo-orchitis is the most common cause of scrotal pain 1
• Ultrasound findings include enlarged epididymis with increased Doppler flow 1
• Can present with chronic or recurrent symptoms 1
• Scrotal wall thickening and reactive hydrocele are common associated findings 1

3. Testicular Malignancy (Must Rule Out)

• Any hydrocele in a man in their 60s requires exclusion of underlying testicular tumor 4, 3
• Testicular tumors can present with secondary hydrocele formation 4
• The patient's age is atypical for germ cell tumors but does not exclude other testicular malignancies 1
• Previous hormone replacement therapy history requires consideration, though direct causation is not established 1

4. Segmental Testicular Infarction

• Presents as focal testicular pain and appears as wedge-shaped avascular area on ultrasound 1
• Can also present as round lesions with variable flow 1
• Less common but important to identify 1

Management Algorithm

Step 1: Urgent Ultrasound Findings Determine Next Steps

If ultrasound shows:

Normal Testes with Simple Hydrocele

• Diagnose post-vasectomy pain syndrome for right-sided symptoms 5
• Conservative management of left hydrocele if asymptomatic 2
• Initiate pain management protocol (see below)

Epididymal Enlargement/Increased Vascularity

• Obtain urinalysis and urine culture 1
• Initiate empiric antibiotic therapy combined with NSAIDs 5
• Consider sexually transmitted infection testing if risk factors present 1

Any Solid Mass or Complex Hydrocele

• Immediate urology referral for consideration of orchiectomy 1, 3
• Obtain tumor markers (AFP, β-hCG, LDH) prior to surgery 1
• CT abdomen/pelvis for staging if malignancy confirmed 1

Step 2: Pain Management for Post-Vasectomy Pain Syndrome

If imaging excludes acute pathology and malignancy:

• First-line: NSAIDs combined with scrotal support 5
• Second-line: Trial of antibiotics (even without confirmed infection) - empiric antibiotic therapy may provide relief in chronic testicular pain 5
• Third-line: Spermatic cord block for diagnostic and therapeutic purposes 5
• Consider transcutaneous electrical nerve stimulation (TENS) 5
• Tricyclic antidepressants or gabapentinoids for neuropathic pain component 5

Step 3: Multidisciplinary Pain Management

• Referral to pain management clinic if conservative measures fail after 3-6 months 5
• Avoid chronic opioid therapy - should only be considered after comprehensive pain management program completion 5
• Orchiectomy is a last resort and should only be considered when pain severely diminishes quality of life and all conservative measures have failed 5

Critical Pitfalls to Avoid

• Never assume a hydrocele is benign without proper ultrasound characterization - testicular tumors can be masked by surrounding fluid 4, 3
• Do not delay imaging in patients over 60 with new or changing scrotal findings 1
• Avoid empiric orchiectomy for pain relief alone without documented pathology 5
• Do not restart testosterone therapy without addressing fertility concerns and understanding its effects on testicular function 1

Special Considerations for Transgender Patients

• Previous hormone replacement therapy may have affected testicular size and function, but does not preclude malignancy 1
• Current absence of hormone therapy means normal testicular evaluation principles apply 1
• Standard cancer screening and diagnostic protocols should be followed without modification 1

Follow-Up Strategy

• If initial ultrasound is reassuring but pain persists, consider repeat imaging in 3-6 months 1
• Annual testicular self-examination education regardless of findings 1
• Monitor for development of new masses or changes in hydrocele characteristics 2