What is the next step in evaluating a patient with intermittent testicular and groin pain after erection, with normal testicles and no current pain, after a stat ultrasound has been ordered?

Management of Intermittent Post-Erection Testicular Pain with Normal Examination

In a patient with intermittent testicular and groin pain occurring only after erections, with currently normal examination and no acute pain, the stat ultrasound should be reviewed for any structural abnormalities, but if normal, no further imaging or urgent intervention is indicated—this represents a benign functional pain syndrome that can be managed conservatively with reassurance and observation. 1, 2

Clinical Context and Differential Diagnosis

The timing of pain exclusively after erections in the absence of acute symptoms or physical findings makes testicular torsion, trauma, and infection highly unlikely:

• Testicular torsion presents with abrupt onset of severe scrotal pain, not intermittent pain triggered by erections, and would show abnormal findings on examination 1
• The American College of Radiology notes that torsion is rare in adults over 35 years and requires immediate intervention within 6-8 hours due to risk of testicular loss 1, 2
• Epididymitis typically presents with gradual onset pain, scrotal tenderness, and may show abnormal urinalysis—none of which are present in this case 1, 2

Role of the Ordered Ultrasound

The stat ultrasound in this clinical scenario serves to exclude structural pathology rather than diagnose an acute emergency:

• Duplex Doppler ultrasound is the established first-line imaging modality for scrotal evaluation, combining grayscale and color Doppler assessment 2, 3, 4
• The examination should assess testicular homogeneity, size, echotexture, and perfusion using both color and power Doppler 2, 5
• The contralateral testicle serves as an internal control for comparison 1, 5

Expected Findings in This Patient

Given the normal examination and absence of acute pain, the ultrasound will likely show:

• Normal testicular size, echogenicity, and perfusion bilaterally 2, 5
• No evidence of masses, cysts, or structural abnormalities requiring intervention 5
• Possible incidental findings like small epididymal cysts (<0.5 cm) or subclinical varicoceles, which are not clinically significant in this context 6

Evidence for Conservative Management

Research specifically addressing chronic scrotal pain with normal examination demonstrates that ultrasound rarely reveals clinically significant pathology:

• A study of 111 patients with chronic scrotal pain and normal physical examination found that scrotal ultrasound revealed no clinically significant abnormalities—only small epididymal cysts and subclinical varicoceles 6
• After median follow-up of 12 months, 70% continued to have intermittent pain but no serious scrotal pathology developed 6
• The study concluded that scrotal ultrasound has no diagnostic value in patients with chronic scrotal pain when physical examination and urinalysis are normal 6

Management Algorithm

If Ultrasound is Normal:

• Reassure the patient that no structural abnormality or surgical emergency exists 6
• Explain that intermittent pain related to erections without physical findings represents a benign functional syndrome 6
• No further imaging or urological intervention is required 6
• Conservative management includes observation and symptomatic treatment if needed 6

If Ultrasound Shows Abnormalities:

• Intratesticular mass or hypoechoic lesion: Requires tumor markers (AFP, beta-hCG, LDH) and urological consultation for possible inguinal orchiectomy 7, 5
• Macrocalcifications: Warrant consideration of testicular biopsy 7, 5
• Microcalcifications alone: Can be observed without biopsy 7, 5
• Varicocele or epididymal cysts: Generally benign findings that do not require intervention unless symptomatic 6

Critical Pitfalls to Avoid

• Do not pursue aggressive workup in the absence of physical findings or concerning ultrasound abnormalities—this leads to unnecessary anxiety and procedures 6
• Do not dismiss the patient's symptoms, but provide appropriate reassurance based on objective findings 6
• Do not order serial imaging for intermittent functional pain with normal initial ultrasound 6
• Recognize that patient history may suggest extrascrotal causes of referred pain, such as low back pain or prior regional surgery 6

Long-Term Prognosis

Patients with chronic intermittent scrotal pain and normal examination typically have a benign course without development of serious pathology, even when symptoms persist 6.