What are the recommended treatments and evaluations for scrotal swelling that has persisted for 1 week?

Scrotal Swelling for 1 Week: Evaluation and Management

Immediate Priority: Rule Out Testicular Torsion First

Although scrotal swelling persisting for 1 week makes testicular torsion less likely, you must still exclude it immediately because testicular viability becomes compromised within 6-8 hours of symptom onset, and any delay beyond this window significantly increases the risk of testicular loss. 1, 2

Key Clinical Features to Assess

Testicular torsion characteristics:

• Sudden, severe onset of pain (not gradual) 3
• More common in adolescents and postpubertal boys, rare over age 35 1, 2
• Absence of urinary symptoms or urethral discharge 3
• Negative Prehn sign (pain NOT relieved with testicular elevation) 2

Epididymitis characteristics (most likely diagnosis in adults with 1-week duration):

• Gradual onset of pain over hours to days 3
• Unilateral testicular pain and tenderness with palpable epididymal swelling 1
• May have urinary symptoms or urethral discharge 1
• Positive Prehn sign (pain relieved with elevation) 2

Diagnostic Workup Algorithm

Step 1: Immediate Duplex Doppler Ultrasound

Order scrotal ultrasound with Doppler immediately—this is the first-line imaging modality with 96-100% sensitivity for detecting torsion. 1

Key ultrasound findings to identify:

For torsion:

• Decreased or absent testicular blood flow compared to contralateral side 1
• "Whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
• Enlarged heterogeneous testis, ipsilateral hydrocele, scrotal wall thickening 1

For epididymitis:

• Enlarged epididymis with INCREASED blood flow on color Doppler 1
• Scrotal wall thickening and hydrocele common 1
• Up to 20% concomitant orchitis 1

Critical pitfall: False-negative Doppler evaluations occur in 30% or more of cases with partial torsion or spontaneous detorsion—never let a normal ultrasound override high clinical suspicion. 2

Step 2: Laboratory Evaluation for Epididymitis

If ultrasound excludes torsion, immediately obtain:

• Gram-stained smear of urethral exudate or intraurethral swab (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1
• Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 1
• Urinalysis and urine culture for Gram-negative bacteria 1
• Syphilis serology and HIV counseling/testing 1

Important caveat: Normal urinalysis does NOT exclude either torsion or epididymitis. 2, 3

Treatment Based on Diagnosis

If Testicular Torsion Confirmed or Highly Suspected

Immediate urological consultation and surgical exploration—do not delay for any reason. 2, 3

• Surgical detorsion must occur within 6-8 hours of symptom onset to prevent permanent ischemic damage 2
• Bilateral orchiopexy required to prevent contralateral torsion 2

If Epididymitis Diagnosed (Most Likely with 1-Week Duration)

Start empiric antibiotic therapy immediately before culture results are available. 1, 3

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 1, 3

For men >35 years or with urinary tract instrumentation/surgery (likely enteric organisms):

• Ofloxacin 300 mg orally twice daily for 10 days 1

Note: Ofloxacin is contraindicated in persons ≤17 years of age. 1

Adjunctive therapy:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1

Follow-Up Requirements

Re-evaluate within 3 days if no improvement occurs—this requires reassessment of both diagnosis and therapy, with consideration of hospitalization. 1, 3

If swelling and tenderness persist after completing antibiotics, perform comprehensive evaluation to exclude:

• Testicular cancer 1
• Tuberculous or fungal epididymitis 1
• Testicular abscess or infarction 1

Sexual Partner Management (If STI-Related)

Refer sex partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset. 1, 3

• Instruct patient to avoid sexual intercourse until both patient and partners complete therapy and are symptom-free 1, 3

Other Differential Diagnoses to Consider

Acute idiopathic scrotal edema:

• Rare, self-limiting, usually painless with marked scrotal wall thickening 1
• Diagnosis of exclusion with normal testes and epididymis on ultrasound 1

Segmental testicular infarction:

• Classic wedge-shaped avascular area on ultrasound 1
• May require MRI if ultrasound equivocal 1

Incarcerated inguinal hernia, Fournier's gangrene, or trauma:

• Consider these emergent conditions until proven otherwise 4