What is the recommended evaluation and treatment for a 14-year-old with intermittent testicular pain and a small lump on the epididymis?

Evaluation and Management of Intermittent Testicular Pain with Epididymal Lump in a 14-Year-Old

This 14-year-old requires urgent Duplex Doppler ultrasound to rule out intermittent (partial) testicular torsion, which is the most critical diagnosis to exclude given the episodic nature of pain, even though the epididymal lump suggests a benign epididymal cyst. 1, 2

Immediate Diagnostic Priority: Rule Out Intermittent Torsion

The pattern of infrequent, episodic testicular pain in an adolescent is highly concerning for intermittent (partial) testicular torsion, where the testicle twists and spontaneously untwists, causing pain that comes and goes. 2 This is a surgical emergency that can progress to complete torsion with testicular loss if not addressed. 2

Why This Takes Priority Over the Epididymal Lump

• Intermittent torsion occurs more frequently in adolescents, with testicular torsion having a bimodal distribution peaking in neonates and postpubertal boys. 1, 3
• The episodic pain pattern is characteristic of partial torsion (<450 degrees), where the testicle twists and untwists spontaneously. 2
• Normal imaging between episodes does not rule out intermittent torsion, as MRI and ultrasound may appear normal when the testicle is not twisted. 2
• Testicular viability is compromised if complete torsion is not treated within 6-8 hours, making early recognition critical. 2

Required Diagnostic Workup

Urgent Duplex Doppler Ultrasound

Order a Duplex Doppler ultrasound of the scrotum immediately, which should include: 1, 2

• Grayscale examination to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity). 1, 2
• Color Doppler assessment of testicular perfusion (96-100% sensitivity for torsion). 1, 2
• Power Doppler to enhance detection of slow flow, particularly useful in adolescents. 1, 2
• Bilateral comparison using the contralateral testicle as an internal control. 1, 2
• Spectral Doppler analysis looking for diminished arterial velocity and decreased diastolic flow suggestive of partial torsion. 2

Key Ultrasound Findings to Differentiate Diagnoses

For intermittent torsion: 2

• Diminished arterial velocity and decreased diastolic flow on Doppler
• May show the "whirlpool sign" if imaged during an episode
• Less severe symptoms than complete torsion but still requires surgical intervention

For epididymal cyst (likely cause of the palpable lump): 4, 5

• Echo-free cystic structure in the epididymis on ultrasound
• Benign mass that is more common than previously thought in prepubertal and adolescent age
• Usually asymptomatic and self-limiting

For epididymitis (less likely given age and sexual history): 6, 7

• Enlarged epididymis with increased blood flow on color Doppler
• Gradual onset of pain (not episodic)
• May have scrotal wall thickening and hydrocele

Management Algorithm

If Intermittent Torsion is Suspected or Confirmed

Immediate urological consultation and surgical exploration is mandatory, even if symptoms have resolved at the time of evaluation. 2 The surgical procedure should include: 1

• Bilateral orchiopexy to prevent future torsion episodes (82% of patients with intermittent torsion have the "bell-clapper" deformity predisposing both testicles to torsion). 1
• Surgical outcomes are better when intervention occurs within 12 hours of symptom onset, though the critical window is 6-8 hours. 2

If Epididymal Cyst is Confirmed and Torsion is Ruled Out

Conservative management is the treatment of choice for asymptomatic or minimally symptomatic epididymal cysts in adolescents. 4, 5

• Clinical follow-up to document stability of the mass is justified for asymptomatic cysts. 5
• Surgical excision is recommended only if the cyst becomes symptomatic (causing significant discomfort or enlargement). 5
• Epididymal cysts are benign, self-limiting in the majority of cases, and more common than previously recognized in this age group. 4

Critical Clinical Pitfalls to Avoid

• Do not assume the epididymal lump explains the intermittent pain without first ruling out torsion—these can be coincidental findings. 2
• Do not rely on normal imaging between pain episodes to exclude intermittent torsion, as the testicle may appear normal when untwisted. 2
• Do not delay urological consultation if clinical suspicion for intermittent torsion is high, even with reassuring ultrasound findings. 2
• Color Doppler has variable sensitivity (69-96.8%) for testicular torsion, with false-negative evaluations occurring in up to 30% of cases, particularly with partial torsion. 1

Follow-Up Requirements

• If treated conservatively for epididymal cyst: Schedule follow-up in 3 months to reassess the mass and ensure stability. 5
• If pain recurs: Immediate re-evaluation with urgent urological consultation, as this strongly suggests intermittent torsion requiring surgical intervention. 2
• Failure to improve or worsening symptoms warrants comprehensive re-evaluation for other diagnoses including tumor, though this is rare in adolescents. 2