What is the diagnosis and treatment for a 26-year-old male with intermittent suprapubic cramping pain and left testicular pain, tenderness at the top of the left testicle, and pain at the superficial inguinal ring that is relieved with elevation?

Diagnosis: Chronic Epididymitis with Possible Intermittent Spermatic Cord Torsion

Based on the 3-4 year history of intermittent suprapubic and left testicular pain that improves with elevation (positive Prehn sign), tenderness at the superficial inguinal ring and superior pole of the testis, and intact cremasteric reflex, this presentation is most consistent with chronic epididymitis, though intermittent testicular torsion must be definitively excluded given the chronic intermittent nature and pain localization.

Immediate Diagnostic Workup

Obtain Duplex Doppler ultrasound of the scrotum as the essential first-line imaging study, which should include:

• Grayscale assessment of testicular homogeneity, size, and any masses 1, 2
• Color and Power Doppler evaluation comparing testicular perfusion to the contralateral side 1, 2
• Detailed evaluation of the epididymis for enlargement or increased vascularity 2
• Assessment for hydrocele, scrotal wall thickening, or the "whirlpool sign" of spermatic cord twisting 1

The chronic intermittent nature with pain at the superficial inguinal ring raises concern for intermittent testicular torsion, which presents with acute intermittent sharp testicular pain and scrotal swelling interspersed with long symptom-free intervals 3. Physical findings may include horizontal or very mobile testes, anteriorly located epididymis, or bulkiness of the spermatic cord from partial twisting 3.

Laboratory Evaluation

• Obtain urinalysis and urine culture if epididymal enlargement or increased vascularity is found on ultrasound 2
• Consider sexually transmitted infection testing if risk factors are present 2
• Obtain serum tumor markers (AFP, β-HCG, LDH) prior to any surgical intervention if a solid mass or complex hydrocele is identified, as any hydrocele in a man requires exclusion of underlying testicular tumor 4, 2

Differential Diagnosis by Likelihood

Most Likely: Chronic Epididymitis/Epididymo-orchitis

• This is the most common cause of scrotal pain in adults, characterized by enlarged epididymis with increased Doppler flow 1, 2
• Can present with chronic or recurrent symptoms 2
• The positive Prehn sign (pain relief with elevation) supports this diagnosis 1
• Tenderness at the superior pole of the testis is consistent with epididymal involvement 2

Must Exclude: Intermittent Testicular Torsion

• The 3-4 year history of intermittent pain with localization at the superficial inguinal ring (spermatic cord) is concerning for this diagnosis 3
• Intermittent torsion occurs in patients with a "bell-clapper" deformity found in 82% of cases 1
• This is critical because it requires bilateral prophylactic orchiopexy to prevent complete torsion and testicular loss 1, 3
• Ultrasound may be normal between episodes, but MRI can identify the bell-clapper deformity with 83% sensitivity 1

Consider: Genitofemoral or Ilioinguinal Nerve Entrapment

• Pain at the superficial inguinal ring suggests possible nerve entrapment along the inguinal canal 5
• This can cause referred testicular pain and is often overlooked 5
• May respond to conservative treatment including soft tissue mobilization and stretching 5

Less Likely but Important: Segmental Testicular Infarction

• Presents as focal testicular pain and appears as a wedge-shaped avascular area on ultrasound 1, 2
• Can also present as round lesions with variable Doppler flow 1, 2

Treatment Algorithm

If Ultrasound Shows Epididymal Enlargement/Increased Vascularity:

• Initiate empiric antibiotic therapy combined with NSAIDs 2
• Antibiotics may be useful even when infection has not been definitively identified 6
• Recommend scrotal elevation and supportive care 1
• Follow-up in 2-4 weeks to assess response

If Ultrasound is Normal but Intermittent Torsion Cannot be Excluded:

• Immediate urology referral for consideration of bilateral prophylactic orchiopexy 1, 3
• The chronic intermittent nature with pain at the spermatic cord level warrants surgical exploration and fixation to prevent testicular loss 3
• Early elective orchiopexy improves testicular salvage in patients with intermittent torsion 3

If Conservative Management Fails:

• Trial of spermatic cord block or transcutaneous electrical nerve stimulation for pain relief 6
• Consider antidepressants for chronic pain management 6
• Referral to multidisciplinary pain management clinic before considering opiate therapy 6
• Orchiectomy should only be considered when all conservative efforts have failed and a pathologic condition is found, not for pain relief alone 6

Critical Clinical Pitfalls

• Do not dismiss chronic intermittent testicular pain as benign without excluding intermittent torsion, as this can lead to acute complete torsion and testicular loss 3
• Normal ultrasound does not exclude intermittent torsion if clinical suspicion remains high based on the pattern of intermittent pain and physical findings 1
• The intact cremasteric reflex does not rule out torsion, particularly intermittent or partial torsion 1
• Any solid mass or complex hydrocele requires immediate urology referral and tumor marker evaluation before surgical intervention 2
• In approximately 50% of chronic testicular pain cases, the cause remains undetermined, but musculoskeletal and neuropathic causes should be considered 5

Given this patient's specific presentation with pain at the superficial inguinal ring and chronic intermittent nature over 3-4 years, urology referral is warranted regardless of ultrasound findings to definitively exclude intermittent torsion and consider prophylactic bilateral orchiopexy 1, 3.