What is the treatment for an elderly man with a swollen testicle?

Treatment for Swollen Right Testicle in an Elderly Man

The immediate priority is urgent testicular ultrasound with Duplex Doppler to differentiate between testicular torsion (requiring emergency surgery within 6-8 hours), epididymitis/epididymo-orchitis (requiring antibiotics), and testicular malignancy (requiring orchiectomy), as these three conditions represent the primary diagnostic considerations in elderly men with testicular swelling. 1, 2

Initial Diagnostic Approach

Clinical Assessment

• Onset and character of pain: Abrupt, severe pain suggests testicular torsion, while gradual onset indicates epididymitis 1, 2
• Associated symptoms: Fever, dysuria, and urethral discharge point toward infection; nausea/vomiting can occur with torsion 3
• Duration of swelling: Chronic, painless swelling (months to years) raises concern for testicular malignancy 4
• Age consideration: Testicular torsion is rare in men over 35 years, making epididymitis and malignancy more likely in elderly patients 1

Mandatory Imaging

• Duplex Doppler ultrasound of the scrotum is the first-line imaging study with 69-96.8% sensitivity and 87-100% specificity 1, 2
• Key ultrasound findings to assess:
  • Blood flow patterns: Decreased/absent flow suggests torsion; increased flow indicates epididymitis 1, 2
  • "Whirlpool sign": Twisted spermatic cord diagnostic of torsion 1, 2
  • Intratesticular vs. extratesticular mass: Any intratesticular mass is malignant until proven otherwise 3
  • Epididymal enlargement: Suggests epididymo-orchitis 2

Treatment Algorithm Based on Diagnosis

If Testicular Torsion is Suspected or Confirmed

• Immediate urological consultation without delay 1, 2
• Surgical exploration and detorsion within 6-8 hours of symptom onset to prevent permanent testicular loss 1, 2
• Do not delay surgery for imaging if clinical suspicion is high 1
• Bilateral orchiopexy is performed during surgery to prevent contralateral torsion 1

Critical pitfall: While torsion is rare in elderly men, it cannot be excluded based on age alone, and delayed diagnosis results in testicular loss 1, 5

If Epididymitis/Epididymo-Orchitis is Diagnosed

This is the most common cause of testicular pain in adults, representing approximately 600,000 cases annually in the United States 1

Antibiotic therapy:

• Doxycycline 100 mg orally twice daily for at least 10 days for acute epididymo-orchitis caused by Chlamydia trachomatis 6
• For gonococcal epididymo-orchitis: Doxycycline 100 mg orally twice daily for at least 10 days (after appropriate ceftriaxone) 6
• Adjust antibiotics based on age, sexual history, and risk factors 2

Supportive measures:

• Bed rest, scrotal elevation, and analgesics until inflammation subsides 1
• Follow-up to assess treatment response 3

Important caveat: Normal urinalysis does not exclude epididymitis 1, 2

If Testicular Mass/Malignancy is Identified

• Obtain serum tumor markers (AFP, β-HCG, LDH) before any intervention 3
• Immediate urological referral for radical inguinal orchiectomy 3
• Never perform scrotal biopsy or scrotal incision for suspected malignancy—only inguinal approach is appropriate 7
• Discuss sperm banking before therapeutic intervention in reproductive-age men 3
• Abdominopelvic CT scan after orchiectomy to assess for metastatic disease 3

Age consideration: While seminoma typically occurs in men aged 30-49 years, it can present in elderly patients (case reported at age 90), so malignancy must remain in the differential 4, 8

Management of Stage I Seminoma in Elderly Patients (if diagnosed)

• Surveillance, adjuvant radiotherapy (20-30 Gy), or single-agent carboplatin are all acceptable options 3, 8
• Disease-specific survival for stage I disease is 99% regardless of management strategy 3
• Conventional therapies are tolerable for most elderly men with stage I seminoma 8

Critical Clinical Pitfalls to Avoid

• Never rely on the Prehn sign alone to differentiate epididymitis from torsion—it has poor sensitivity and specificity 7
• False-negative Doppler evaluations occur in 30% of cases, particularly with partial torsion or spontaneous detorsion 1
• Significant overlap exists in clinical presentation between different causes of acute scrotal pain 1, 2
• Do not delay urological consultation when torsion cannot be definitively ruled out 1, 2
• Consider rare presentations: perforated appendicitis can present with scrotal signs via patent processus vaginalis 9

Laboratory Studies

• Complete blood count, creatinine, electrolytes, liver enzymes if intratesticular mass identified 3
• Urinalysis to assess for infection, though normal results do not exclude pathology 1, 2
• Serum tumor markers (AFP, β-HCG, LDH) if malignancy suspected 3