Intermittent Left Testicular Pain with Pain During Erection
This presentation most likely represents chronic epididymitis or epididymo-orchitis, and you should initiate empiric antibiotic therapy while ruling out other important causes through physical examination and ultrasound.
Immediate Diagnostic Priorities
The key clinical features to assess during physical examination include:
- Palpable epididymal swelling or tenderness on the left side, which would support epididymitis as the primary diagnosis 1, 2
- Testicular position and orientation - a high-riding, horizontally oriented testicle would suggest torsion, though the intermittent nature and 2-month duration make this less likely 3
- Presence or absence of cremasteric reflex - absence suggests torsion, though again the chronic intermittent pattern argues against this 3
- Positive Prehn sign (pain relief with testicular elevation) supports epididymitis over torsion 4
- Urethral discharge or dysuria - though often asymptomatic, these would support sexually transmitted epididymitis 1, 2
Critical Differential Diagnosis
Most Likely: Chronic Epididymitis
- The intermittent nature over 2 months with pain during erection (increased blood flow/pressure) is consistent with chronic or recurrent epididymitis 1, 4
- In sexually active men under 35 years, Chlamydia trachomatis or Neisseria gonorrhoeae are the most common causes 1, 2
Must Rule Out: Testicular Torsion
- While the 2-month duration makes acute torsion unlikely, intermittent torsion can present with recurrent episodes of pain 4, 3
- This is a surgical emergency requiring intervention within 6-8 hours of an acute episode to prevent testicular loss 2, 4
- The sudden onset during erection could theoretically represent torsion episodes
Other Important Considerations
- Varicocele: Can cause dull, aching testicular pain that may worsen with increased blood flow during erection 5
- Testicular tumor: Must be excluded if symptoms persist after antimicrobial therapy 1
- Chronic orchialgia: A diagnosis of exclusion when no structural cause is found 6, 7
Recommended Diagnostic Workup
Obtain the following immediately:
- Urethral Gram stain showing >5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 1, 2
- Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis (can be done on first-void urine or urethral swab) 1, 2
- Duplex Doppler ultrasound of the scrotum - this is the first-line imaging with 96-100% sensitivity for torsion and can also identify epididymitis, varicocele, or masses 2, 4
Empiric Treatment Approach
For a sexually active man under 35 years, initiate empiric antibiotic therapy immediately while awaiting test results:
- Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 2
- This regimen covers both gonococcal and chlamydial infection 1, 2
Adjunctive measures:
- Scrotal elevation, rest, and NSAIDs until inflammation subsides 1
- Avoid sexual activity until treatment is completed 1
Critical Follow-Up Parameters
Reassess within 3 days - failure to improve requires reevaluation of both diagnosis and therapy 1
If symptoms persist after completing antibiotics, the differential expands to include:
- Testicular tumor
- Abscess
- Testicular infarction
- Chronic orchialgia requiring pain management strategies 1, 6, 7
Important Caveats
- Do not delay surgical consultation if clinical suspicion for torsion is high - proceed directly to urological evaluation without waiting for imaging 2, 4
- The pain during erection is an important clue: it suggests increased vascular congestion exacerbating underlying inflammation (epididymitis) or venous congestion (varicocele), rather than the classic presentation of torsion 5
- If over 35 years or history of receptive anal intercourse, consider enteric organisms and use Levofloxacin 500 mg orally once daily for 10 days instead 1, 2
- The priapism guidelines 1 are not relevant here, as this patient describes pain with erection, not prolonged unwanted erection lasting >4 hours