What is the appropriate diagnosis and treatment for a 26-year-old male with groin and testicular pain, sensitivity to touch and movement, and wave-like pain, with normal white blood cell (WBC) count and urinalysis results?

Diagnosis and Management of Acute Testicular Pain in a 26-Year-Old Male

This patient requires urgent Duplex Doppler ultrasound of the scrotum immediately to rule out testicular torsion, which remains a surgical emergency even in adults, though epididymitis is statistically more likely given his age. 1, 2

Immediate Diagnostic Approach

The wave-like pain pattern with sensitivity to touch and movement, combined with normal WBC and urinalysis, creates diagnostic uncertainty that mandates imaging rather than empiric treatment. 1

Key Clinical Features to Assess

Testicular torsion characteristics:

• Abrupt onset of severe pain (though can be gradual in partial torsion) 2
• Negative Prehn sign (pain NOT relieved with testicular elevation) 2
• High-riding, horizontally oriented testicle on exam 3
• Absent cremasteric reflex 3
• Normal urinalysis does NOT exclude torsion 2

Epididymitis/epididymo-orchitis characteristics:

• More gradual onset of pain (though this is not absolute) 2
• Most common cause of acute scrotal pain in adults and adolescents, representing approximately 600,000 cases annually in the United States 2
• May have abnormal urinalysis, but normal urinalysis does NOT exclude epididymitis 2
• Positive Prehn sign (pain relief with elevation) 4

Critical Diagnostic Pitfall

There is significant overlap in clinical presentation between testicular torsion and epididymitis, making clinical diagnosis alone unreliable. 2 The wave-like pain pattern could represent intermittent torsion, which is particularly dangerous as it can lead to false-negative Doppler evaluations. 2

Urgent Imaging Protocol

Duplex Doppler ultrasound is the first-line imaging study with sensitivity of 69-96.8% and specificity of 87-100%. 2

Essential Ultrasound Components

Grayscale examination should assess: 1, 2

• Testicular homogeneity and size
• The "whirlpool sign" of twisted spermatic cord (96% sensitivity, most specific finding for torsion) 1, 2
• Scrotal wall thickening and hydrocele

Color/Power Doppler assessment should evaluate: 1, 2

• Testicular perfusion compared to contralateral side (use as internal control)
• Power Doppler is more sensitive for slow flow states 1
• Epididymal blood flow (increased in epididymitis, normal/decreased in torsion)

Spectral Doppler analysis should document: 2

• Arterial waveforms in upper, mid, and lower poles of each testicle
• Resistive index and diastolic flow patterns

Differential Diagnosis by Likelihood in This Age Group

Most Likely: Epididymitis/Epididymo-orchitis (60-70% probability)

Epididymitis is overwhelmingly the most common cause of testicular pain in adults. 2

Ultrasound findings include: 1

• Enlarged epididymis with increased blood flow on color Doppler
• Scrotal wall thickening and hydrocele common
• Up to 20% concomitant orchitis rate 1

Second Most Likely: Testicular Torsion (15-20% probability despite age)

While testicular torsion is rare in patients over 35 years, it absolutely can occur in 26-year-olds and remains a surgical emergency. 2 The bimodal distribution peaks in neonates and postpubertal boys, but the second peak extends into young adulthood. 2, 5

Ultrasound findings include: 2

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

Less Likely Considerations

Segmental testicular infarction: 1, 2

• Classic wedge-shaped avascular area on ultrasound
• Can also present as round lesions with variable Doppler flow
• Median age 37-38 years

Varicocele with pain: 6

• Typically described as dull, aching, or throbbing pain
• Rarely acute or wave-like
• Visible on ultrasound as dilated pampiniform plexus

Management Algorithm Based on Ultrasound Results

If Torsion Confirmed or Highly Suspected

Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset is mandatory. 2 Testicular viability is compromised beyond this window, with salvage rates dropping precipitously after 12 hours. 2

Do NOT delay surgery for additional imaging or testing. 2 Even if ultrasound shows some residual flow (suggesting partial torsion), surgical exploration is still required as partial torsion requires surgical intervention. 2

If Epididymitis/Epididymo-orchitis Diagnosed

Treatment includes: 2

• Bed rest and scrotal elevation
• Analgesics (NSAIDs preferred for anti-inflammatory effect)
• Appropriate antibiotic therapy based on age and risk factors
• In sexually active young adults, cover for Chlamydia trachomatis and Neisseria gonorrhoeae (doxycycline 100mg BID for 10 days plus ceftriaxone 500mg IM once)

If Ultrasound is Equivocal or Normal BUT Clinical Suspicion Remains High

When clinical suspicion for torsion remains high despite normal or equivocal Doppler, immediate urological consultation and surgical exploration should proceed. 2 False-negative Doppler evaluations occur in 30% or more of cases, particularly with partial torsion, spontaneous detorsion, or early presentation. 2

Color Doppler sensitivity ranges from 69-96.8%, meaning up to 30% of torsion cases can have misleading ultrasound findings. 2

Critical Time-Sensitive Considerations

The 6-8 hour window from symptom onset is critical for testicular salvage. 2, 4 However, the patient's description of "wave-like" pain raises concern for intermittent torsion, which means the clock may have started earlier than the current presentation suggests. 2

Any delay in surgical intervention for confirmed torsion increases the risk of testicular loss and compromises salvage rates. 2 Therefore, ultrasound should be performed stat (within 1 hour), and if torsion is confirmed, the patient should be in the operating room within 2-3 hours of presentation.