What are the management and treatment options for testicular pain?

Management and Treatment of Testicular Pain

Immediate Priority: Rule Out Testicular Torsion

Any patient presenting with acute testicular pain must be evaluated immediately as a potential surgical emergency until testicular torsion is excluded. 1, 2

The critical time window is 6-8 hours from symptom onset to prevent permanent testicular loss, with surgical outcomes significantly better when intervention occurs within 12 hours. 1

Diagnostic Algorithm

Step 1: Rapid Clinical Assessment

Obtain these specific details immediately:

• Onset pattern: Abrupt, severe pain suggests torsion; gradual onset suggests epididymitis 1
• Age: Torsion has bimodal peaks (neonates and postpubertal boys); epididymitis more common in adults >25 years 1
• Prehn sign: Pain NOT relieved by testicular elevation (negative Prehn sign) indicates torsion 1
• Systemic symptoms: Fever more common with infection 1
• Urinalysis: Normal urinalysis does NOT exclude torsion 1

Step 2: Risk Stratification Using TWIST Score

For intermediate clinical suspicion (TWIST score 1-5), proceed immediately to imaging. 1 For high clinical suspicion, do not delay surgical consultation for imaging—proceed directly to operating room. 2

Step 3: Urgent Doppler Ultrasound (When Appropriate)

Order Duplex Doppler ultrasound with these specific components: 1

• Grayscale examination: Look for "whirlpool sign" (96% sensitivity), enlarged heterogeneous testis, hydrocele, scrotal wall thickening 1
• Color/Power Doppler: Compare blood flow to contralateral testis; Power Doppler more sensitive for prepubertal boys with naturally slow flow 1
• Spectral Doppler: Assess upper, mid, and lower poles for regional flow variations 1

Critical pitfall: Doppler sensitivity ranges only 69-96.8%, meaning false-negatives occur in up to 30% of cases, particularly with partial torsion or spontaneous detorsion. 1 When clinical suspicion remains high despite normal Doppler, proceed to surgical exploration. 1

Treatment Based on Diagnosis

Testicular Torsion (Surgical Emergency)

Immediate urological consultation and surgical exploration within 6-8 hours. 1, 2 The procedure involves:

• Inguinal or scrotal exploration with detorsion 1
• Assessment of testicular viability 1
• Bilateral orchiopexy to prevent contralateral torsion (82% have Bell-clapper deformity) 1

Post-operative care: bed rest, scrotal elevation, analgesics until inflammation subsides. 1

Epididymitis/Epididymo-orchitis (Most Common in Adults)

This accounts for approximately 600,000 cases annually in the United States and is the most common cause in adults. 1

Treatment regimen:

• Doxycycline 100 mg orally twice daily for at least 10 days for acute epididymo-orchitis caused by Chlamydia trachomatis 3
• For gonococcal causes: Doxycycline 100 mg orally twice daily for at least 10 days 3
• Bed rest, scrotal elevation, analgesics 1
• Ibuprofen for pain management (usual adult dose 200 mg initially, up to 400 mg every 4-6 hours as needed) 4

Important caveat: Up to 20% have concomitant orchitis. 1 Ultrasound shows enlarged epididymis with increased blood flow on color Doppler. 1

Torsion of Testicular Appendage (Most Common in Prepubertal Boys)

Conservative management is appropriate: 1

• Bed rest and scrotal elevation 1
• Analgesics (ibuprofen as above) 4
• The "blue dot sign" is pathognomonic but only visible in 21% of cases 1
• Ultrasound shows normal testicular perfusion with localized hyperemia near the appendage 1

Chronic Testicular Pain (>3 Months Duration)

For patients with chronic orchialgia failing conservative management: 5, 6

• Initial trial: NSAIDs (ibuprofen 400 mg three times daily with food to minimize GI effects) 4
• Spermatic cord block for diagnostic and therapeutic purposes 6
• If cord block provides temporary complete relief, microsurgical denervation of the spermatic cord shows reasonable effectiveness 6
• Other surgical options: epididymectomy, vasovasostomy 5
• Last resort: inguinal orchiectomy for refractory cases 5

Hydrocele/Epididymal Cysts (Symptomatic)

For symptomatic cysts >5 cm causing pain or discomfort: 7

• Sclerotherapy as primary treatment (especially in patients >40 years) 7
• Polidocanol 3% preferred for local anesthetic properties 7
• Success rates: 67% single treatment for hydroceles (87% overall); 46% single treatment for epididymal cysts (84% with repeat treatment) 7
• Follow-up at 3,6, and 12 months post-procedure 7

Rare emergency: Tension hydrocele can compromise testicular perfusion and requires emergent operative drainage. 8

Critical Pitfalls to Avoid

• Never delay surgical consultation for imaging when clinical suspicion for torsion is high—testicular viability depends on time. 2
• Do not start antibiotics empirically without ruling out torsion first—this delays correct diagnosis and treatment. 2
• Remember that testes can torse and detorse spontaneously, causing intermittent symptoms that may mislead diagnosis. 9
• Normal urinalysis does NOT exclude either torsion or epididymitis. 1
• Significant clinical overlap exists between all causes of acute scrotal pain—rely on imaging and maintain high index of suspicion. 1
• Point-of-care handheld Doppler by ED physicians shows 97.8% specificity for ruling out torsion and can be used for rapid triage. 10

Age-Specific Considerations

• Neonates/prepubertal boys: Torsion of testicular appendage most common, but testicular torsion still possible 1
• Adolescents (postpubertal): Highest risk for testicular torsion 1
• Adults >25 years: Epididymitis most likely, but torsion still possible until age 35 1
• Adults >35 years: Testicular torsion rare; consider malignancy, chronic pain syndromes 1