What are the appropriate steps to take for a patient experiencing severe, sudden, or gradual right testicular pain, possibly accompanied by nausea, vomiting, or fever?

Right Testicular Pain: Evaluation and Management

Immediate Action Required

Right testicular pain must be treated as testicular torsion until proven otherwise, requiring immediate urological consultation and surgical exploration within 6-8 hours of symptom onset to prevent permanent testicular loss. 1

Initial Clinical Assessment

Critical Time-Sensitive Features

Determine the onset pattern immediately:

• Sudden, severe onset with nausea/vomiting strongly suggests testicular torsion 1, 2
• Gradual onset over hours to days suggests epididymitis 1
• Testicular torsion presents with a high-riding testicle, absent cremasteric reflex, and negative Prehn sign (pain NOT relieved by elevation) 1, 3

Age-Based Risk Stratification

• Adolescents and young adults: Testicular torsion is the primary concern, with peak incidence in postpubertal boys and an annual rate of 3.8 per 100,000 males under 18 years 1, 2
• Adults over 35 years: Epididymitis becomes more common, often associated with urinary tract infections or instrumentation 4
• Prepubertal boys: Torsion of testicular appendage is most common 1

Diagnostic Algorithm

High Clinical Suspicion (Sudden Onset, Severe Pain, Absent Cremasteric Reflex)

Proceed directly to surgical exploration WITHOUT imaging - do not delay for ultrasound when clinical suspicion is high, as testicular viability is compromised after 6-8 hours 1, 2

Intermediate Clinical Suspicion

Urgent Duplex Doppler ultrasound is indicated 1:

• Grayscale findings to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
• Color Doppler assessment showing decreased or absent testicular blood flow (96-100% sensitivity) 1
• Power Doppler is particularly useful in prepubertal patients with normally low flow 1
• Compare to the contralateral testicle as an internal control 1

Critical Ultrasound Pitfalls

False-negative Doppler occurs in 30% of cases, particularly with: 1

• Partial torsion (<450 degrees) where arterial flow may persist
• Spontaneous detorsion
• Early presentation within first few hours
• Prepubertal boys with normally reduced flow

If clinical suspicion remains high despite normal Doppler, proceed to surgical exploration immediately 1

Differential Diagnosis by Presentation

Testicular Torsion (Surgical Emergency)

• Abrupt onset of severe unilateral pain 1, 2
• Nausea and vomiting common 5, 2
• High-riding, horizontally oriented testicle 3, 6
• Absent cremasteric reflex 2, 3
• Normal urinalysis does NOT exclude torsion 1
• Ultrasound: Absent/decreased flow, whirlpool sign, enlarged heterogeneous testis 1

Epididymitis (Most Common in Adults)

• Gradual onset of pain over hours to days 1
• May have fever, dysuria, or urethral discharge 4
• In men <35 years: Usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae 4
• In men >35 years: Usually caused by gram-negative enteric organisms from urinary tract 4
• Ultrasound: Enlarged epididymis with INCREASED blood flow on Doppler 1

Torsion of Testicular Appendage

• Most common in prepubertal boys 1
• "Blue dot sign" pathognomonic but only present in 21% of cases 1
• Normal testicular perfusion with localized hyperemia near appendage 1

Management Protocol

Confirmed or Highly Suspected Testicular Torsion

1. Immediate urological consultation 1, 2
2. Surgical exploration and detorsion within 6-8 hours of symptom onset 1, 2
3. Bilateral orchiopexy during surgery to prevent contralateral torsion (82% have Bell-clapper deformity) 1
4. Testicular salvage rates decline dramatically after 6-8 hours, with orchiectomy rate of 42% in delayed cases 2

Manual Detorsion (Temporizing Measure Only)

• May be attempted while awaiting surgery, but never delays surgical exploration 5, 3
• Ultrasound guidance can improve success rate 3, 6
• Most testes torse medially ("opening a book"), so detorse laterally 3

Confirmed Epididymitis

Empiric antibiotic therapy based on age and risk factors 4:

• Men <35 years or sexually active: Cover C. trachomatis and N. gonorrhoeae
• Men >35 years: Cover gram-negative enteric organisms
• Hospitalization indicated for severe pain, fever, or concern for abscess 4
• Supportive care: Bed rest, scrotal elevation, analgesics 4

Diagnostic Workup for Epididymitis

Before initiating antibiotics 4:

• Gram stain of urethral exudate (>5 PMNs per oil immersion field indicates urethritis)
• Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
• Urinalysis and urine culture
• Syphilis serology and HIV testing

Key Clinical Pitfalls to Avoid

1. Never delay surgical exploration for imaging when clinical suspicion for torsion is high 1, 2
2. Normal urinalysis does NOT exclude testicular torsion 1
3. Normal Doppler ultrasound does NOT exclude torsion - false-negative rate up to 30% 1
4. Significant overlap exists in clinical presentation between torsion and epididymitis 1
5. Intermittent torsion can present with recurrent episodes of pain that spontaneously resolve 1, 7
6. Fever does NOT exclude torsion - can occur with testicular necrosis 4