From the Guidelines
I strongly recommend a scrotal ultrasound to evaluate the patient's testicular pain, as it is the most appropriate initial imaging modality for acute onset of scrotal pain without trauma or antecedent mass in an adult, according to the American College of Radiology Appropriateness Criteria 1. This recommendation is based on the latest evidence from 2024, which suggests that ultrasound is the established first-line imaging modality for acute scrotal disease and can be used to diagnose most scrotal disorders when combined with clinical history and physical examination 1. The patient's symptoms of intermittent sharp testicular pain that worsened after masturbation warrant investigation to rule out conditions such as epididymitis, testicular torsion, varicocele, or hydrocele. Although the patient is currently pain-free, the recent 4/10 sharp pain necessitates further evaluation to prevent potential tissue damage from conditions like testicular torsion, which requires urgent intervention 1. In the meantime, the patient should avoid activities that exacerbate the pain and can take over-the-counter pain relievers like acetaminophen or ibuprofen (400-600mg every 6 hours as needed) for pain management. Some key points to consider in the evaluation of the patient's condition include:
- The importance of prompt diagnosis and treatment of testicular conditions, particularly torsion, to prevent tissue damage and preserve fertility 1
- The use of ultrasound to evaluate testicular perfusion and identify potential abnormalities, such as an enlarged heterogeneous testis or absence of color Doppler flow in the testis or spermatic cord 1
- The consideration of clinical history and physical examination findings, such as the presence of fever, waxing and waning pain, and laboratory markers for infection, to distinguish between different testicular conditions 1.
From the Research
Diagnosis and Imaging
- The patient's symptoms of testicular pain, particularly after stopping and then resuming masturbation, warrant further investigation to determine the cause of the pain.
- A scrotal ultrasound has been ordered for diagnosis, which is in line with recommendations from studies such as 2 and 3, stating that ultrasound is the imaging modality of choice for evaluating scrotal abnormalities due to its high resolution, Doppler capabilities, and lack of ionizing radiation.
Potential Causes of Testicular Pain
- The patient's symptoms could be indicative of several potential causes, including epididymitis, testicular torsion, or other scrotal pathology, as discussed in studies 4 and 5.
- It is essential to consider "must not miss" diagnoses, such as testicular torsion, which can lead to infarction of the testis if not promptly treated, as noted in 5.
Role of Ultrasound in Diagnosis
- Ultrasound is capable of differentiating between various etiologies of acute scrotal pain and swelling, including epididymitis and testicular torsion, as stated in 3.
- The use of color and spectral Doppler analysis allows for the assessment of vascular perfusion, which can aid in the diagnosis of conditions such as testicular torsion, as mentioned in 3 and 5.
- Studies such as 6 support the use of scrotal ultrasound in patients presenting with scrotal symptoms, particularly when a confident diagnosis cannot be made or there is failure to respond to treatment.