What is the workup for a hard tender testicle?

Workup for Hard Tender Testicle

A hard tender testicle requires immediate evaluation with scrotal ultrasound with Doppler to differentiate between testicular torsion (a surgical emergency requiring intervention within 6-8 hours), testicular rupture, testicular tumor, and epididymitis/epididymo-orchitis. 1

Immediate Clinical Assessment

Critical Time-Sensitive Features to Identify

• Onset and character of pain: Abrupt onset of severe scrotal pain suggests testicular torsion, while gradual onset suggests epididymitis 1
• Age of patient: Testicular torsion has bimodal distribution (neonates and postpubertal boys), while epididymitis is most common in adults over 25 years 1
• Cremasteric reflex: An absent ipsilateral cremasteric reflex is the most accurate clinical sign of testicular torsion 2
• Prehn sign: Pain that is NOT relieved with testicular elevation (negative Prehn sign) suggests torsion 1
• Associated symptoms: Nausea and vomiting are common with torsion 3, 4
• History of trauma: Scrotal ecchymosis, swelling, or difficulty identifying testicular contours suggests testicular rupture 5
• Urinary symptoms: Blood at urethral meatus, gross hematuria, or inability to void may indicate concomitant urethral injury 5

Physical Examination Findings

• Testicular position: A high-riding testicle suggests torsion 4
• Testicular contour: Loss of normal testicular contour or palpable mass raises concern for rupture or tumor 5
• "Blue dot sign": A tender nodule with blue discoloration on the upper pole suggests torsion of testicular appendage (most common in prepubertal boys) 1, 2
• Scrotal wall changes: Marked scrotal wall thickening with minimal pain may suggest acute idiopathic scrotal edema 1

Diagnostic Testing Algorithm

Laboratory Studies

• Urinalysis: Obtain to evaluate for urinary tract infection or urethritis, though normal urinalysis does NOT exclude testicular torsion 1
• Gram stain of urethral exudate: If epididymitis suspected, evaluate for >5 polymorphonuclear leukocytes per oil immersion field 5
• Serum tumor markers: If testicular mass suspected, obtain β-HCG, AFP, and LDH before any intervention 5

Imaging Studies

Duplex Doppler ultrasound of the scrotum is the first-line imaging modality and should include: 1

• Grayscale examination: Assess for testicular homogeneity, the "whirlpool sign" of twisted spermatic cord (96% sensitivity), enlarged heterogeneous testis, ipsilateral hydrocele, and scrotal skin thickening 1
• Color Doppler assessment: Evaluate testicular perfusion with sensitivity of 96-100% for torsion (decreased or absent blood flow) versus hyperemia in epididymitis 1
• Power Doppler: Particularly useful for prepubertal testes with normally slow flow 1
• Spectral Doppler analysis: Assess upper, mid, and lower poles of each testicle, comparing to contralateral side as internal control 1

Key Ultrasound Findings by Diagnosis

Testicular torsion: 1

• Decreased or absent blood flow to affected testicle
• "Whirlpool sign" of twisted spermatic cord
• Enlarged heterogeneous hypoechoic testis
• Ipsilateral hydrocele and scrotal skin thickening

Testicular rupture: 5

• Loss of testicular contour
• Heterogeneous echotexture of parenchyma

Epididymitis/epididymo-orchitis: 1

• Enlarged epididymis with INCREASED blood flow on Doppler
• Thickening of scrotal wall
• Hydrocele

Testicular tumor: 5

• Intratesticular mass confirmed on ultrasound
• Requires serum tumor markers and chest radiograph

Critical Management Decisions

When to Proceed Directly to Surgery WITHOUT Imaging

If clinical suspicion for testicular torsion is high (TWIST score >5), proceed immediately to surgical exploration without delay for imaging studies. 1, 4 The four- to eight-hour window before permanent ischemic damage is critical. 4

When Imaging is Indicated

• Intermediate clinical suspicion (TWIST score 1-5): Obtain urgent Duplex Doppler ultrasound 1
• Equivocal clinical presentation: Ultrasound can help differentiate between diagnoses 1

Definitive Management Based on Diagnosis

Testicular torsion: 1

• Immediate urological consultation and surgical exploration with detorsion
• Bilateral orchiopexy to prevent recurrence
• Surgical outcomes are better when surgery occurs within 12 hours of symptom onset

Testicular rupture: 5

• Scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable)
• Early exploration and repair prevents complications such as ischemic atrophy and infection

Epididymitis: 5

• Empiric antibiotic therapy based on age and risk factors
• Ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 10 days (if age <35 years or sexually active)
• Ofloxacin 300 mg orally twice daily for 10 days or levofloxacin 500 mg orally once daily for 10 days (if age >35 years or enteric organisms suspected)
• Bed rest, scrotal elevation, and analgesics until fever and inflammation subside

Testicular tumor: 5

• Inguinal orchiectomy is primary treatment
• Sperm banking must be discussed before any therapeutic intervention

Critical Pitfalls to Avoid

• False-negative Doppler evaluations occur in 30% or more of cases, particularly with partial torsion, spontaneous detorsion, or early presentation 1
• Color Doppler sensitivity ranges from 69-96.8%, making it imperfect—never delay surgical exploration when clinical suspicion is high 1
• Prepubertal boys normally have reduced intratesticular blood flow, which can lead to false-positive evaluations—always use the contralateral testis as internal control 1
• Failure to improve within 3 days of treatment requires reevaluation of both diagnosis and therapy 5
• Persistent swelling and tenderness after antimicrobial therapy completion warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 5