What is the appropriate evaluation and treatment for a patient with intermittent testicular pain that occurs with erection and persists afterwards?

Evaluation and Management of Intermittent Testicular Pain Associated with Erection

This patient requires urgent Duplex Doppler ultrasound of the scrotum to evaluate for intermittent testicular torsion, which can present with episodic pain that comes and goes, and immediate urological consultation should be arranged given the concerning pattern of symptoms. 1

Critical Diagnostic Consideration

Intermittent (partial) testicular torsion must be ruled out urgently, as this condition presents with recurrent episodes of testicular pain that resolve spontaneously when the testicle untwists, and can progress to complete torsion with testicular loss. 1, 2 The pattern of pain occurring with erection and persisting afterward is particularly concerning for this diagnosis, as increased blood flow during erection may exacerbate symptoms of partial vascular compromise. 3

Key Clinical Features Supporting Intermittent Torsion:

• Recurrent episodes of pain over 2 weeks - up to half of patients with testicular torsion report previous similar episodes 3
• Pain that comes and goes - characteristic of partial torsion where the testicle twists and spontaneously untwists 1
• Relationship to erection - increased testicular blood flow during erection may unmask partial vascular compromise
• Important caveat: MRI and ultrasound cannot definitively rule out intermittent torsion, as imaging between episodes may appear normal 4

Immediate Diagnostic Workup

Physical Examination Findings to Assess:

• Testicular position: high-riding testis suggests torsion 3
• Cremasteric reflex: absent in torsion, present in epididymitis 1
• Prehn sign: pain NOT relieved with testicular elevation suggests torsion 1
• Testicular consistency: firm, swollen, tender testis in torsion 3
• Epididymal involvement: enlarged epididymis with gradual pain onset suggests epididymitis 1, 5

Imaging Protocol:

Duplex Doppler ultrasound is the first-line imaging modality and should include: 4, 1

• Grayscale examination to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
• Color Doppler assessment of testicular perfusion (96-100% sensitivity) 1
• Power Doppler for enhanced detection of slow flow 1
• Bilateral comparison using the contralateral asymptomatic testicle as internal control 1

Critical pitfall: False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion between episodes. 1 If clinical suspicion remains high despite normal imaging, proceed directly to surgical exploration. 6

Laboratory Studies:

• Urinalysis - normal urinalysis does NOT exclude testicular torsion 1
• If age <35 years and sexually active: urethral swab or first-void urine for N. gonorrhoeae and C. trachomatis testing 4
• If age >35 years: consider enteric organisms as cause of epididymitis 4

Differential Diagnosis by Age and Presentation

Most Likely Diagnoses in This Clinical Scenario:

Intermittent/Partial Testicular Torsion:

• Partial torsion (<450 degrees) presents with diminished arterial velocity and decreased diastolic flow on Doppler 1
• May have less severe symptoms but still requires surgical intervention 1
• Testicular viability compromised if not treated within 6-8 hours of complete torsion 1

Epididymitis (if patient is sexually active and <35 years):

• Gradual onset of pain (unlike the abrupt onset typical of complete torsion) 1
• Enlarged epididymis with increased blood flow on Doppler 1
• May have abnormal urinalysis, though normal urinalysis doesn't exclude it 1
• Concomitant orchitis occurs in up to 20% of cases 4

Treatment Algorithm

If Intermittent Torsion is Suspected or Confirmed:

Immediate urological consultation and surgical exploration is mandatory, even if symptoms have resolved at time of evaluation. 1, 6 Surgical outcomes are better when intervention occurs within 12 hours of symptom onset, though the critical window is 6-8 hours. 1

• Bilateral orchiopexy should be performed to prevent recurrence 3
• Do not delay surgery for imaging if clinical suspicion is high 6
• Manual detorsion may be attempted but surgical exploration remains necessary 2

If Epididymitis is Confirmed:

For patients <35 years (presumed STI etiology): 4

• Ceftriaxone 250 mg IM single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days

For patients >35 years (presumed enteric organisms): 4

• Ofloxacin 300 mg orally twice daily for 10 days OR
• Levofloxacin 500 mg orally once daily for 10 days

Adjunctive measures: bed rest, scrotal elevation, and analgesics until fever and inflammation subside 4

Follow-up Requirements:

• Failure to improve within 3 days requires reevaluation of diagnosis and therapy 4
• Persistent swelling/tenderness after antimicrobial completion warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 4
• Any patient with negative imaging but ongoing symptoms requires daily follow-up until symptoms resolve 6

Critical Clinical Pitfalls

The most dangerous error is dismissing intermittent symptoms as benign. 6 The 2-week history of recurrent pain is a red flag that cannot be ignored, as intermittent torsion can progress to complete torsion with permanent testicular loss. 1, 3

Do not rely solely on imaging - if clinical suspicion for torsion is high and imaging cannot be obtained and interpreted within 1-2 hours, proceed directly to scrotal exploration. 6 The significant overlap in clinical presentation between torsion and epididymitis makes diagnosis challenging, and when in doubt, surgical exploration is the safest approach. 1