Treatment for Swollen Testicles
The treatment for swollen testicles depends critically on the underlying cause, with testicular torsion requiring immediate surgical exploration within 6-8 hours to prevent testicular loss, while epididymitis is treated with empiric antibiotics, scrotal elevation, and analgesics. 1, 2
Immediate Assessment: Rule Out Surgical Emergency
The first priority is distinguishing testicular torsion from other causes, as this determines whether emergency surgery is needed:
Clinical Features Suggesting Testicular Torsion (Surgical Emergency)
- Sudden, severe onset of scrotal pain 1, 2
- More common in adolescents and young men (bimodal distribution: neonates and postpubertal boys) 2
- Absent cremasteric reflex 3
- Negative Prehn sign (pain NOT relieved with testicular elevation) 2
- If suspected, proceed directly to urological consultation—do not delay for imaging 1, 2
Clinical Features Suggesting Epididymitis (Medical Management)
- Gradual onset over days to weeks 3, 4
- Urinary symptoms (frequency, dysuria) 3, 4
- Positive Prehn sign (pain relief with elevation) 3
- More common in men >25 years or those with risk factors for STIs 1, 4
Diagnostic Workup
For Suspected Torsion
- Urgent Doppler ultrasound only if clinical suspicion is intermediate (TWIST score 1-5) 2
- Look for decreased/absent blood flow and "whirlpool sign" of twisted spermatic cord 2
- Critical pitfall: False-negative Doppler can occur with partial torsion or spontaneous detorsion—maintain high clinical suspicion 2, 3
For Suspected Epididymitis
- Urinalysis and urine culture 1, 3
- Gram stain of urethral discharge (>5 PMNs per oil immersion field indicates urethritis) 1
- Nucleic acid amplification test for Chlamydia trachomatis and Neisseria gonorrhoeae 1
- Doppler ultrasound showing enlarged epididymis with increased blood flow 2
Treatment by Diagnosis
Testicular Torsion
Immediate surgical exploration and detorsion within 6-8 hours of symptom onset 2
- Testicular viability is compromised after 6 hours 1
- Surgical outcomes are better when surgery occurs within 12 hours 2
- Bilateral orchiopexy is typically performed to prevent future torsion 2
Epididymitis: Age <35 Years (STI-Related)
Recommended regimen 1:
Adjunctive measures 1:
- Bed rest until fever and inflammation subside 1
- Scrotal elevation and support 1, 3
- Analgesics (NSAIDs) for pain control 1, 3
Epididymitis: Age >35 Years (Enteric Organisms)
Recommended regimen 1:
- Ofloxacin 300 mg orally twice daily for 10 days OR
- Levofloxacin 500 mg orally once daily for 10 days 1
Important caveat: Rising fluoroquinolone resistance in E. coli may necessitate alternative antimicrobials based on local resistance patterns 6
Same adjunctive measures as above 1
Follow-Up and Red Flags
Reassessment Timeline
- Failure to improve within 3 days requires reevaluation of diagnosis and therapy 1
- If pain becomes sudden or severe during treatment, urgent reassessment for torsion is mandatory 3
Persistent Symptoms After Antibiotic Completion
Swelling and tenderness persisting after completing antimicrobials requires comprehensive evaluation for 1:
- Testicular tumor or cancer 1
- Abscess formation 1, 7
- Testicular infarction 2, 7
- Tuberculous or fungal epididymitis 1
Partner Management for STI-Related Epididymitis
- Refer sex partners if contact occurred within 60 days preceding symptom onset 1
- Patient should avoid sexual intercourse until both partners complete therapy and are asymptomatic 1
Critical Pitfalls to Avoid
- Never give a trial of antibiotics without imaging if torsion cannot be clinically excluded—testicular viability is time-dependent 1, 2
- Normal urinalysis does NOT exclude either torsion or epididymitis 1, 2, 3
- Significant overlap exists in clinical presentation between different causes of scrotal pain 2
- In patients with rapidly increasing β-HCG and testicular mass, consider testicular cancer and initiate appropriate workup 1
- Do not delay urological consultation if any clinical suspicion for torsion exists 1, 2, 3