Painless Testicular Swelling in a Young Adult
This 23-year-old male with painless testicular swelling most likely has epididymitis or a hydrocele, but testicular torsion must be urgently excluded despite the atypical presentation, requiring immediate Doppler ultrasound evaluation. 1
Critical Initial Assessment
The absence of pain is atypical for testicular torsion but does not exclude it, particularly in cases of partial torsion or intermittent torsion. 1 The patient's description of the testicle feeling "up inside" his body raises concern for possible intermittent torsion with spontaneous detorsion, which can present with less severe or fluctuating symptoms. 1
Key clinical features to immediately evaluate:
- Onset timing: Abrupt onset suggests torsion (even if painless), while gradual onset over days favors epididymitis 1
- Cremasteric reflex: Though not perfectly reliable, its absence increases torsion suspicion 2
- Testicular position and lie: High-riding or horizontal testis suggests torsion 1
- Prehn sign: Pain relief with elevation suggests epididymitis, not torsion 1
Diagnostic Algorithm
Immediate Doppler ultrasound is mandatory to assess testicular perfusion, regardless of pain absence. 1, 3 The ultrasound should include:
- Grayscale examination to assess testicular homogeneity and identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
- Color Doppler assessment of testicular perfusion comparing both testicles (96-100% sensitivity) 1
- Power Doppler for enhanced detection of slow flow 1
Critical pitfall: False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion. 1 A normal ultrasound cannot definitively exclude torsion if clinical suspicion remains high. 2
Age-Specific Considerations
While testicular torsion is uncommon in adults over 25 years, it absolutely occurs in this age group and should not be dismissed. 1, 3 At 23 years old, this patient falls just outside the typical postpubertal peak but remains at risk. 1 Epididymitis is the most common cause of testicular symptoms in adults, representing approximately 600,000 cases annually in the United States. 1
Management Based on Ultrasound Findings
If decreased or absent testicular blood flow is detected:
- Immediate urological consultation for surgical exploration without delay 1, 3
- Testicular viability depends on intervention within 6-8 hours of true symptom onset 1
- Even with one week of symptoms, if intermittent torsion is present, the testicle may still be salvageable 1
If normal blood flow with epididymal enlargement and hyperemia:
- Diagnosis of epididymitis is confirmed 1
- Obtain urinalysis (though normal urinalysis does not exclude epididymitis) 1
- Treat with appropriate antibiotics based on age and risk factors
- Supportive care with scrotal elevation, NSAIDs, and rest 1
If hydrocele or other benign findings:
- Manage conservatively with observation
- Urology referral for persistent or enlarging hydrocele
Additional Differential Considerations
- Testicular tumor: Painless swelling in a young adult warrants consideration of malignancy, though typically presents as a firm mass rather than diffuse swelling
- Varicocele: Usually described as "bag of worms" sensation, more common on left side
- Inguinal hernia: The sensation of testicle being "up inside" could represent intermittent herniation of bowel into scrotum
Immediate Action Plan
Do not delay imaging with empiric antibiotic treatment in this patient. 3 The one-week duration and painless nature may falsely reassure, but partial or intermittent torsion can present exactly this way. 1 Order urgent Doppler ultrasound today, and if any concern for diminished flow exists, proceed directly to urological consultation for surgical exploration. 1, 3