Quick Testicular Pain Assessment in Primary Care
Immediate Action Required
Any patient presenting with acute testicular pain must be treated as testicular torsion until proven otherwise, requiring immediate urological consultation without delay, as testicular salvage depends on surgical intervention within 6-8 hours of symptom onset. 1
Critical Time-Sensitive Assessment
History (obtain rapidly, <5 minutes)
- Onset timing: Abrupt, severe pain suggests torsion; gradual onset suggests epididymitis 1
- Duration: Document exact time pain started—every hour matters for testicular viability 1
- Age: Bimodal distribution with peaks in neonates and postpubertal boys (12-18 years) for torsion; adults >25 years more likely epididymitis 1
- Previous episodes: Up to 50% of torsion patients report prior similar episodes 2
- Associated symptoms: Nausea/vomiting common with torsion 3, 4
Physical Examination (focused, <5 minutes)
- Testicular position: High-riding testis strongly suggests torsion 4
- Prehn sign: Pain NOT relieved with testicular elevation indicates torsion 1
- Cremasteric reflex: Absent reflex suggests torsion, but presence does NOT exclude it 3
- Testicular consistency: Firm, swollen, tender testis 2
- Scrotal skin: Thickening and edema may be present 1
Decision Algorithm
HIGH SUSPICION for Torsion (any of the following):
- Sudden severe pain + high-riding testis
- Absent cremasteric reflex + severe pain
- Age 12-18 years + acute onset
- Negative Prehn sign
→ Call urology IMMEDIATELY, proceed directly to OR—do NOT delay for imaging 1, 4
INTERMEDIATE SUSPICION (TWIST score 1-5):
- Mixed clinical features
- Uncertain timing
→ Call urology AND order STAT Doppler ultrasound simultaneously—do not wait for imaging results to consult 1
LOW SUSPICION:
- Gradual onset over days
- Adult >35 years
- Positive urinalysis for infection
→ Order Doppler ultrasound, but maintain low threshold for urgent urology consultation 1
Imaging Considerations (if ordered)
- Duplex Doppler ultrasound is first-line imaging with 69-97% sensitivity and 87-100% specificity 1
- Key findings for torsion: Decreased/absent blood flow, "whirlpool sign" of twisted cord 1
- Critical pitfall: Normal ultrasound does NOT exclude torsion—false-negative rate up to 30%, especially with partial torsion or early presentation 1, 3
- Never delay surgical exploration for imaging if clinical suspicion is high 4, 5
Management While Awaiting Urology
- Analgesia: Provide adequate pain control
- NPO status: Keep patient fasting for potential immediate surgery 1
- Manual detorsion (if urology delayed >30 minutes): Rotate testis outward (like opening a book) 1-2 full turns—may provide temporary relief but surgical exploration still mandatory 3, 6
- Document exact time: Record symptom onset time and consultation time for surgical team 1
Common Pitfalls to Avoid
- Waiting for imaging results before calling urology—consultation should be simultaneous with imaging order 1, 5
- Relying on cremasteric reflex—its presence does not exclude torsion 3
- Assuming normal urinalysis excludes torsion—urinalysis is typically normal in torsion 1
- Delaying for "observation"—testicular salvage rate drops dramatically after 6 hours 1, 4
- Trusting a negative ultrasound alone—clinical suspicion trumps imaging 1, 5
Age-Specific Differential Priorities
- Prepubertal boys (<12 years): Torsion of testicular appendage most common, but always rule out testicular torsion first 1
- Adolescents (12-18 years): Testicular torsion is the primary concern—highest risk group 1, 4
- Adults (>25 years): Epididymitis most common (600,000 cases/year in US), but torsion still possible until age 35 1