What causes right testicular pain during sex and hardness of the testicle?

Testicular Torsion Until Proven Otherwise

Right testicular pain during sex with testicular hardness is testicular torsion until proven otherwise and requires immediate urological consultation and scrotal ultrasound with Doppler—do not delay for imaging if clinical suspicion is high, as surgical intervention within 6-8 hours is critical to prevent testicular loss. 1

Why This Is a Surgical Emergency

• The combination of acute testicular pain and a firm/hard testicle strongly suggests testicular torsion, which occurs when the spermatic cord twists, cutting off blood supply to the testicle 1, 2
• Testicular viability is compromised if not treated within 6-8 hours of symptom onset, with surgical outcomes significantly better when surgery occurs within 12 hours 1
• The "hardness" you describe represents testicular swelling and edema from vascular compromise—this is a red flag finding 1

Immediate Action Required

• Call urology immediately for surgical consultation—do not wait for imaging if clinical suspicion is high, as imaging delays can result in testicular loss 1, 2
• If ultrasound is performed, it should be Duplex Doppler showing decreased or absent blood flow to the affected testicle and potentially the "whirlpool sign" of the twisted spermatic cord 1
• The trauma history (sexual activity) can be misleading—progressive worsening pain with a firm, tender testicle suggests torsion rather than simple traumatic injury 2

Key Clinical Features Supporting Torsion

• Sudden onset of severe scrotal pain (which can occur during physical activity including sex) 1, 2
• Negative Prehn sign—pain is NOT relieved when the testicle is elevated 1
• Firm, swollen testicle on examination 1, 2
• Normal urinalysis does not exclude testicular torsion 1
• Nausea and vomiting are common associated symptoms 3

Critical Pitfall to Avoid

• Do not start antibiotics for presumed epididymitis—this would delay the correct diagnosis and treatment, risking permanent testicular loss 2
• Epididymitis has gradual onset of pain (not sudden during sex), positive Prehn sign (pain relief with elevation), and increased blood flow on ultrasound—the opposite of what you're describing 1, 2

Alternative Consideration: Intermittent Torsion

• If symptoms resolve spontaneously, this could represent intermittent testicular torsion where the testicle torses and detorses 4, 5
• Intermittent torsion is characterized by acute episodes of sharp testicular pain and scrotal swelling with long symptom-free intervals 5
• Physical findings may include horizontal or very mobile testes, anteriorly located epididymis, or bulkiness of the spermatic cord from partial twisting 5
• Even if symptoms resolve, this requires elective bilateral orchiopexy to prevent future complete torsion, as 82% of patients with intermittent torsion have the "bell-clapper" deformity predisposing to torsion 1, 5

Definitive Management

• Surgical exploration with detorsion of the affected testis, assessment of viability, and bilateral orchiopexy (fixing both testicles to prevent recurrence) 1
• The contralateral testicle must also be fixed during surgery, as the anatomical predisposition is typically bilateral 1