Management of Left Testicular Redness and Warmth with Normal Urinalysis
This presentation requires urgent scrotal ultrasound with Doppler to differentiate between testicular torsion and epididymitis, as a normal urinalysis does not exclude either diagnosis and both conditions can present with overlapping clinical features. 1
Immediate Clinical Assessment
The key priority is determining whether this represents testicular torsion (a surgical emergency) versus epididymitis (medical management). The following features must be rapidly assessed:
Critical History Elements
- Pain onset timing: Abrupt, severe pain suggests torsion, while gradual onset over hours to days suggests epididymitis 1, 2
- Patient age: Torsion peaks in adolescents (12-18 years) and is rare after age 35; epididymitis predominates in adults over 25 years 1, 3
- Associated symptoms: Fever, urinary symptoms, or urethral discharge favor epididymitis, while nausea/vomiting are common with torsion 1, 2
- Trauma history: If present, consider testicular rupture which requires different management 4
Physical Examination Findings
- Prehn sign: Negative (no relief with scrotal elevation) suggests torsion 1, 2
- Cremasteric reflex: Absence suggests torsion, though presence does not exclude it 3, 5
- Testicular position: High-riding testis suggests torsion 3, 6
- Testicular contours: Difficulty identifying contours may indicate rupture if trauma occurred 1
Critical Pitfall
Normal urinalysis does NOT exclude either torsion or epididymitis. 1 The clinical presentations overlap significantly, and pyuria may be absent in epididymitis while present in some torsion cases due to inflammatory response.
Risk Stratification and Immediate Action
High Suspicion for Torsion (Any of the Following)
- Abrupt onset of severe pain
- Adolescent patient
- Negative Prehn sign
- Absent cremasteric reflex
- High-riding testis
Action: Immediate urological consultation for surgical exploration WITHOUT waiting for ultrasound. 1, 3 Delays beyond 6-8 hours significantly increase risk of permanent ischemic damage and orchiectomy. 3, 5
Intermediate Suspicion
- Mixed clinical features
- Adult patient with acute onset
- Equivocal physical findings
Action: Obtain urgent Duplex Doppler ultrasound while keeping urology immediately available. 1 Do not delay surgical consultation if ultrasound cannot be performed and interpreted within 1-2 hours. 7
Lower Suspicion (Favoring Epididymitis)
- Gradual onset over days
- Adult over 25 years
- Fever present
- Urinary symptoms or urethral discharge
- Positive Prehn sign
Action: Proceed with scrotal ultrasound, but maintain high clinical suspicion as false-negative Doppler can occur with partial torsion or spontaneous detorsion. 1
Diagnostic Imaging
Scrotal ultrasound with Doppler should be obtained to confirm extratesticular pathology and assess testicular blood flow. 4, 1 Key findings:
- Torsion: Decreased or absent testicular blood flow, heterogeneous echotexture 4, 1
- Epididymitis: Increased blood flow to epididymis, enlarged epididymis 1
- Rupture: Loss of testicular contour, heterogeneous parenchyma 4
However, ultrasound should never delay surgical exploration when torsion is strongly suspected clinically. 3, 5
Empiric Treatment While Awaiting Definitive Management
Symptomatic Relief
- Bed rest with scrotal elevation
- Analgesics for pain control
- Avoid delays in definitive evaluation 1
Empiric Antibiotics (Only if Epididymitis Strongly Suspected)
After obtaining cultures, consider starting antibiotics:
- Sexually transmitted etiology (age <35, sexually active): Ceftriaxone 500mg IM once PLUS Doxycycline 100mg PO BID for 10 days 1
- Enteric organisms (age >35, recent instrumentation): Ofloxacin 300mg PO BID for 10 days 1
Do NOT delay surgical consultation to start antibiotics if torsion remains in differential.
Special Considerations
If Trauma History Present
- Assess for testicular rupture: scrotal ecchymosis, swelling, difficulty identifying testicular contours 4, 1
- Check for blood at urethral meatus, hematuria, or inability to void (suggests urethral injury) 4, 1
- Suspected testicular rupture requires prompt surgical exploration regardless of ultrasound findings 4
Mandatory Re-evaluation
If symptoms fail to improve within 3 days of treatment for presumed epididymitis, re-evaluate to exclude tumor, abscess, infarction, or atypical infections. 1
Algorithm Summary
- High suspicion for torsion → Immediate urology consultation for surgical exploration
- Intermediate suspicion → Urgent Doppler ultrasound + urology on standby
- Lower suspicion → Doppler ultrasound + empiric antibiotics if epididymitis confirmed
- Any doubt or imaging unavailable within 1-2 hours → Proceed to surgical exploration 7
The 6-8 hour window from symptom onset is critical for testicular salvage in torsion cases. 3, 5 When in doubt, err on the side of surgical exploration rather than observation.