What is the appropriate course of action for a patient experiencing testicular pain and swelling, potentially indicating testicular torsion, epididymitis, or orchitis?

Testicular Pain and Swelling: Emergency Management

Testicular torsion must be ruled out immediately in any patient presenting with testicular pain and swelling, as surgical intervention within 6-8 hours is critical to prevent permanent testicular loss. 1

Immediate Clinical Assessment

The first priority is distinguishing testicular torsion (a surgical emergency) from other causes based on these key features:

Testicular Torsion (Surgical Emergency)

• Sudden onset of severe scrotal pain 1
• Negative Prehn sign (pain NOT relieved by elevating the testicle) 1
• More common in adolescents with bimodal distribution (neonates and postpubertal boys) 1
• Normal urinalysis does NOT exclude torsion 1
• Nausea and vomiting are common 2

Epididymitis/Epididymo-orchitis

• Gradual onset of pain 1, 3
• Positive Prehn sign (pain relieved with testicular elevation) 3
• Most common cause in adults (approximately 600,000 cases annually in the US) 1
• May have abnormal urinalysis, though normal urinalysis does not exclude it 1
• In sexually active men <35 years: typically C. trachomatis or N. gonorrhoeae 4
• In men >35 years: typically enteric organisms like E. coli 4, 5

Torsion of Testicular Appendage

• Most common cause in prepubertal boys 1, 3
• "Blue dot sign" visible through skin (only in 21% of cases) 1, 3
• Can be managed conservatively 6

Diagnostic Algorithm

High Clinical Suspicion for Torsion (TWIST score ≥6)

Proceed directly to immediate urological consultation and surgical exploration WITHOUT waiting for imaging. 1 Delaying surgery for imaging when clinical suspicion is high risks testicular loss. 3

Intermediate Clinical Suspicion (TWIST score 1-5)

Obtain urgent Duplex Doppler ultrasound with the following protocol: 1

Grayscale examination: 1

• Look for "whirlpool sign" of twisted spermatic cord (96% sensitivity)
• Assess for enlarged heterogeneous testis (may appear hypoechoic)
• Check for ipsilateral hydrocele and scrotal wall thickening

Color/Power Doppler assessment: 1

• Compare testicular perfusion to contralateral side (use as internal control)
• Power Doppler is more sensitive for low-flow states, especially in prepubertal boys
• Sensitivity ranges 69-96.8%, specificity 87-100%

Spectral Doppler analysis: 1

• Assess upper, mid, and lower poles of each testicle
• Look for diminished arterial velocity, decreased/absent diastolic flow, or reversed diastolic flow

Critical Ultrasound Pitfalls

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

• Partial torsion (arterial flow may persist because venous obstruction occurs first)
• Spontaneous detorsion
• Early presentation within first few hours

If clinical suspicion remains high despite normal Doppler, proceed immediately to surgical exploration. 1 The 6-8 hour window for testicular salvage cannot be compromised by imaging limitations.

Management Based on Diagnosis

Confirmed or Highly Suspected Testicular Torsion

Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset. 1, 3 Surgical outcomes are significantly better when surgery occurs within 12 hours. 1

Surgical procedure includes: 1

• Detorsion of affected testis
• Assessment of testicular viability
• Bilateral orchiopexy (82% of patients have Bell-clapper deformity predisposing contralateral testis to torsion) 1

Epididymitis/Epididymo-orchitis

Ultrasound findings: 1

• Enlarged epididymis with increased blood flow on Doppler
• Scrotal wall thickening and possible hydrocele
• Up to 20% have concomitant orchitis

Treatment for sexually active men <35 years: 4

• Ceftriaxone 250 mg IM single dose PLUS
• Doxycycline 100 mg PO twice daily for 10 days 4, 7

Treatment for men >35 years or suspected enteric organisms: 4

• Ofloxacin 300 mg PO twice daily for 10 days OR
• Levofloxacino 500 mg PO once daily for 10 days

Supportive care: 1

• Bed rest
• Scrotal elevation
• Analgesics

Critical follow-up: Failure to improve within 3 days requires reevaluation of diagnosis and therapy. 4 Consider testicular cancer in differential if pain persists after completing antimicrobial treatment. 4

Torsion of Testicular Appendage

Ultrasound findings: 1, 6

• Normal testicular perfusion with localized hyperemia near appendage
• Enlarged, homogeneously echogenic appendix testis medial or posterior to epididymis head
• Hydrocele and scrotal wall thickening common

Management: Conservative treatment with analgesics and observation 6

Age-Stratified Considerations

• Prepubertal boys: Torsion of testicular appendage is most common cause of testicular pain 1
• Adolescents/young adults: Testicular torsion has peak incidence (2.9-3.8 per 100,000 boys <18 years) 1
• Adults <35 years, sexually active: Epididymitis most common, typically STI-related 4
• Adults >35 years: Epididymitis most common (600,000 cases annually), typically enteric organisms; testicular torsion is rare 1, 4

Common Pitfalls to Avoid

• Never delay surgical consultation for imaging when clinical suspicion for torsion is high 3
• Do not start antibiotics empirically without ruling out torsion first - this delays correct diagnosis 3
• Do not rely solely on Doppler ultrasound - false-negative rate up to 30% 1
• Remember that trauma history can be a red herring - progressive worsening pain suggests torsion, not simple traumatic injury 3
• Prepubertal boys normally have reduced intratesticular blood flow - can lead to false-positive Doppler interpretations 1