What are the treatment options for testicle pain and swelling?

Treatment of Testicular Pain and Swelling

The first priority is to immediately rule out testicular torsion through urgent urological consultation, as this surgical emergency requires intervention within 6-8 hours to prevent permanent testicular loss; if torsion is excluded and epididymitis is suspected, initiate empiric antibiotic therapy based on patient age and risk factors. 1

Immediate Assessment: Exclude Surgical Emergencies

Testicular torsion must be considered first in any patient with acute testicular pain and swelling, as delayed treatment beyond 6-8 hours results in irreversible ischemic damage. 1, 2

Red Flags for Testicular Torsion:

• Sudden onset of severe, unilateral scrotal pain 1, 2
• More common in adolescents and young men (bimodal distribution: neonates and ages 12-18) 1, 2
• Negative Prehn sign (pain not relieved with testicular elevation) 1
• Absence of urethritis or urinary tract infection on initial testing 3

Diagnostic Approach:

• If clinical suspicion is high, proceed directly to emergency urological consultation without waiting for imaging 4
• For intermediate suspicion, obtain urgent Duplex Doppler ultrasound showing decreased/absent blood flow and "whirlpool sign" (96-100% sensitivity) 1, 4
• A normal ultrasound does NOT exclude torsion—if clinical suspicion remains high, surgical exploration is still warranted 2

Treatment Algorithm for Epididymitis (After Excluding Torsion)

Once testicular torsion is ruled out, epididymitis becomes the most likely diagnosis, particularly in adults. Empiric antibiotic therapy should be initiated immediately before culture results are available. 3

For Men Under 35 Years or Sexually Active Patients:

Most likely caused by Chlamydia trachomatis or Neisseria gonorrhoeae: 3, 4

• Ceftriaxone 250 mg IM single dose
• PLUS Doxycycline 100 mg orally twice daily for 10 days 3, 5

For Men Over 35 Years or Suspected Enteric Organisms:

Most likely caused by Gram-negative enteric organisms, especially in patients with recent urinary tract instrumentation or anatomical abnormalities: 3

• Ofloxacin 300 mg orally twice daily for 10 days
• OR Levofloxacin 500 mg orally once daily for 10 days 3

For Patients with Cephalosporin or Tetracycline Allergies:

• Use fluoroquinolone regimen (Ofloxacin or Levofloxacin) as above 3

Adjunctive Supportive Measures

All patients with epididymitis should receive symptomatic treatment until fever and local inflammation subside: 3

• Bed rest 3
• Scrotal elevation 3
• Analgesics for pain control 3

Critical Follow-Up and Reassessment

Failure to improve within 3 days requires complete reevaluation of both diagnosis and treatment. 3

Persistent Symptoms After Antibiotic Completion Require Comprehensive Evaluation For:

• Testicular tumor 3
• Abscess formation 3, 6
• Testicular infarction 3
• Tuberculosis or fungal epididymitis (especially in immunocompromised patients) 3

Special Considerations

Bilateral or Alternating Testicular Pain:

• Consider bilateral epididymitis (most common cause in sexually active men under 35) 4
• Rule out bilateral or sequential testicular torsion (occurs in approximately 2% of torsion cases and requires immediate surgical intervention) 4
• Consider viral orchitis (particularly mumps) if systemic viral illness present 4

HIV-Infected Patients:

• Use same treatment regimen as HIV-negative patients for uncomplicated epididymitis 3
• Maintain higher suspicion for fungal and mycobacterial causes in immunosuppressed patients 3

Sexual Partner Management:

• For epididymitis caused by N. gonorrhoeae or C. trachomatis, refer all sexual partners from the preceding 60 days for evaluation and treatment 3
• Instruct patients to avoid sexual intercourse until both patient and partners complete therapy and are asymptomatic 3

Common Pitfalls to Avoid

• Never delay urological consultation for imaging if testicular torsion is strongly suspected clinically—testicular viability decreases significantly after 6-8 hours 1, 2
• Do not rely on cremasteric reflex presence or absence—it is not a reliable indicator of torsion 2
• Do not assume normal urinalysis excludes torsion—urinalysis is typically normal in testicular torsion 1
• Hospitalization should be considered for severe pain suggesting abscess or testicular infarction, fever, or concerns about treatment compliance 3