What is the appropriate evaluation and management for a male patient presenting with bilateral flank pain, testicular pain, and tenderness around the umbilicus and iliac regions?

Evaluation and Management of Bilateral Flank and Testicular Pain

This patient requires immediate evaluation for testicular torsion with urgent Doppler ultrasound of the scrotum, followed by non-contrast CT abdomen/pelvis to evaluate for urolithiasis, as the bilateral nature of symptoms with spontaneous resolution suggests either intermittent testicular torsion or renal colic with referred testicular pain. 1, 2

Immediate Diagnostic Priorities

Rule Out Testicular Torsion First

The bilateral testicular pain with spontaneous resolution is highly concerning for intermittent testicular torsion, which can present with recurrent pain episodes that resolve spontaneously but carry significant risk of future testicular infarction and loss. 2

Key distinguishing features to assess:

• Abrupt onset with spontaneous resolution strongly suggests intermittent torsion rather than epididymitis, which typically has gradual onset over days 2
• Nausea/vomiting occurs in 25% of intermittent torsion cases 2
• The absence of urinary symptoms (dysuria, frequency) makes epididymitis less likely 2
• Bilateral or alternating testicular pain can occur with sequential torsion (2% of cases) or bilateral epididymitis 3

Critical action: Obtain urgent Duplex Doppler ultrasound of bilateral scrotum immediately, even if symptoms have resolved, as false-negative results occur in up to 30% of cases with partial torsion or spontaneous detorsion. 1, 2

Ultrasound Interpretation

The ultrasound must include:

• Grayscale examination to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 2
• Color Doppler assessment of testicular perfusion (96-100% sensitivity) 2
• Power Doppler for detecting low-flow states 1
• Comparison with contralateral testicle as internal control 1

If decreased flow or whirlpool sign is present: Proceed immediately to emergency urological consultation and surgical exploration without delay, as testicular salvage requires intervention within 6-8 hours. 1, 2, 4

If ultrasound shows increased epididymal flow: This suggests bilateral epididymitis, most commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae in sexually active men under 35 years. 3

Evaluate for Urolithiasis

The bilateral flank pain with periumbilical and iliac tenderness strongly suggests urolithiasis with referred testicular pain, which is a common presentation of ureteral stones.

Imaging for Stone Disease

Obtain non-contrast CT abdomen/pelvis as the reference standard for urolithiasis evaluation (97% sensitivity). 5

Key advantages of non-contrast CT:

• Virtually all renal calculi are radiopaque on CT 5
• Rapid acquisition with high spatial resolution 5
• Can detect stones as small as 1mm 5
• Avoids contrast-related complications 5

Do NOT obtain CT with IV contrast as initial imaging, as enhancing renal parenchyma during nephrographic phase obscures stones within the collecting system. 5

Alternative if CT Unavailable

Ultrasound kidneys and bladder combined with KUB radiography can be considered if CT is contraindicated, though sensitivity is lower (79-90% versus 93% for CT). 5

Clinical Decision Algorithm

If Testicular Torsion Confirmed or Highly Suspected:

1. Immediate urological consultation 1, 2
2. Surgical exploration and bilateral orchiopexy within 6-8 hours of symptom onset 1, 4
3. Bilateral orchiopexy is mandatory as bell-clapper deformity is present in 100% of intermittent torsion cases 2

If Bilateral Epididymitis Diagnosed:

For sexually active men under 35 years:

• Ceftriaxone 250mg IM once PLUS Doxycycline 100mg PO twice daily for 10 days 3
• Obtain urethral Gram stain and NAAT for N. gonorrhoeae and C. trachomatis 3
• Scrotal elevation, NSAIDs, bed rest 2
• Reassess in 48-72 hours; if worsening, reconsider torsion 2

For men over 35 years or suspected enteric organisms:

• Ofloxacin 300mg PO twice daily for 10 days OR Levofloxacin 500mg PO once daily for 10 days 3

If Urolithiasis Confirmed:

• Stones ≥6mm have higher risk of passage failure and may require urological intervention 5
• Manage pain with NSAIDs or opioids as needed
• Hydration and observation for stones <5mm
• Urological consultation for stones >5mm or complications (infection, obstruction) 5

Critical Pitfalls to Avoid

Never delay surgical exploration for imaging if clinical suspicion for testicular torsion is high based on history and physical examination. 1, 4

Do not be falsely reassured by:

• Normal ultrasound with partial torsion (false-negative rate up to 30%) 1
• Symptom resolution (intermittent torsion can recur with permanent loss) 2
• Normal urinalysis (does not exclude torsion) 1

The four- to eight-hour window before permanent ischemic damage is critical—any diagnostic uncertainty should favor surgical exploration over observation. 4, 6