What should I do if my testicle is red and warm to touch?

Testicular Redness and Warmth: Immediate Evaluation and Management

Seek immediate medical evaluation, as a red and warm testicle represents a potential surgical emergency requiring urgent assessment to rule out testicular torsion, which can result in testicular loss if not treated within 6-8 hours of symptom onset. 1

Critical First Step: Rule Out Testicular Torsion

Testicular torsion must be excluded first, as it is a surgical emergency where testicular viability becomes compromised without prompt intervention. 2, 1

Key Clinical Features Suggesting Torsion:

• Sudden, severe onset of pain (not gradual) 1, 3
• More common in adolescents and young men (bimodal distribution: neonates and postpubertal boys) 2, 1
• Absence of urinary symptoms or urethral discharge 2
• Negative Prehn sign (pain NOT relieved by elevating the testicle) 1
• Nausea and vomiting are common 3

Immediate Action Required:

• If sudden severe pain or high clinical suspicion exists, proceed directly to emergency urological consultation without waiting for imaging, as testicular viability may be lost within 6-8 hours. 1
• Emergency Doppler ultrasound should be obtained for intermediate suspicion cases, but should never delay surgical exploration when clinical suspicion is high. 1

Alternative Diagnosis: Epididymitis/Epididymo-orchitis

If torsion is ruled out, epididymitis is the most likely diagnosis in adults presenting with testicular redness and warmth. 2, 1

Clinical Features Suggesting Epididymitis:

• Gradual onset of pain (over hours to days, not sudden) 1
• Unilateral testicular pain and tenderness 2
• Palpable swelling of the epididymis 2
• May have urinary symptoms or urethral discharge 2

Diagnostic Workup for Epididymitis:

• Gram-stained smear of urethral exudate or intraurethral swab (>5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 2
• Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis (on intraurethral swab or first-void urine) 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 2
• Syphilis serology and HIV testing 2

Treatment Algorithm

If Epididymitis is Confirmed:

Start empiric antibiotic therapy immediately before culture results are available. 2

For Sexually Active Men <35 Years (Likely STI-Related):

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 2

For Men ≥35 Years or Enteric Organism Suspected:

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 2

Adjunctive Measures:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2

Follow-Up Requirements:

• Reevaluate within 3 days if no improvement occurs 2
• If swelling and tenderness persist after completing antibiotics, comprehensive evaluation is needed to exclude tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 2

Critical Pitfalls to Avoid

Common Diagnostic Errors:

• Never assume epididymitis without considering torsion first, especially in adolescents and young adults, as there is significant overlap in clinical presentation. 1
• Normal urinalysis does NOT exclude testicular torsion 1
• Doppler ultrasound has false-negative rates of 30% or more, particularly with partial torsion or early presentation, so clinical judgment supersedes imaging. 1
• Do not delay surgical consultation for imaging if clinical suspicion for torsion is high, as the 6-8 hour window is critical. 1

Age-Specific Considerations:

• Testicular torsion is rare in men >35 years, making epididymitis more likely in this age group 1
• In adolescents, always maintain high suspicion for torsion regardless of other findings 1, 3

Sexual Partner Management (If STI-Related Epididymitis):

• Refer sex partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset 2
• Avoid sexual intercourse until both patient and partners complete therapy and are symptom-free 2