How to manage a male patient with severe testicular pain, a hard testicle for 7 days, and a 1-day history of fever?

Management of Severe Testicular Pain with Hard Testicle for 7 Days and Fever

Immediate Action Required

This patient requires urgent urological consultation and likely surgical exploration, as the combination of prolonged severe testicular pain, a hard testicle, and new-onset fever suggests either complicated epididymo-orchitis with potential abscess/infarction or delayed presentation of testicular torsion with infarction. 1, 2

Critical Diagnostic Considerations

The 7-day duration with 10/10 pain makes this presentation atypical and concerning:

• Testicular torsion typically presents with acute, sudden onset pain and requires intervention within 6-8 hours to prevent permanent ischemic damage 2, 3. However, the 7-day duration suggests either:

  • Intermittent torsion with recent complete torsion 2
  • Testicular infarction from missed torsion 1
  • This diagnosis becomes less likely with prolonged duration, but cannot be excluded 2, 4

• Severe epididymo-orchitis is more consistent with the timeline, especially with new fever 1, 5. The hard testicle suggests:

  • Severe inflammation with potential abscess formation 1
  • Testicular infarction from venous outflow obstruction 6
  • Pyocele or complicated infection 1

• Testicular abscess or infarction must be considered given the severity, duration, and fever 1, 6

Immediate Diagnostic Workup

Clinical Assessment

• Examine for high-riding, horizontally oriented testicle (suggests torsion even if delayed) 7
• Assess cremasteric reflex (absence suggests torsion, though not reliable in isolation) 4
• Check for urethral discharge (suggests sexually transmitted epididymitis) 1, 5
• Palpate for discrete epididymal enlargement versus diffuse testicular involvement 1, 2

Laboratory Studies

• Urethral Gram stain looking for >5 polymorphonuclear leukocytes per oil immersion field 1, 5
• Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis 1, 5
• Urinalysis and urine culture (though normal urinalysis does not exclude either torsion or epididymitis) 2
• Blood cultures if febrile 1

Urgent Imaging

• Duplex Doppler ultrasound of both testicles immediately 2, 3:
  • Look for absent or decreased blood flow (suggests torsion or infarction) 2, 3
  • Assess for "whirlpool sign" (96% sensitivity for torsion) 2, 3
  • Evaluate for enlarged epididymis with increased flow (epididymitis) 2, 3
  • Identify wedge-shaped avascular areas (segmental infarction) 2
  • Look for fluid collections suggesting abscess 1

Critical pitfall: Ultrasound sensitivity for torsion is only 69-96.8%, and false negatives occur in up to 30% of cases, particularly with partial torsion 2. If clinical suspicion remains high despite imaging, proceed to surgical exploration 2, 3.

Management Algorithm

If Ultrasound Shows Absent/Decreased Flow or High Clinical Suspicion for Torsion:

• Immediate urological consultation for surgical exploration without delay 2, 3
• Even after 7 days, exploration is warranted to assess viability, remove necrotic tissue if present, and perform contralateral orchiopexy 2
• Manual detorsion can be attempted while awaiting surgery if torsion is confirmed 4, 7

If Ultrasound Confirms Epididymo-orchitis:

Hospitalization is strongly indicated given severe pain, fever, and 7-day duration suggesting complicated infection 1. The CDC guidelines specifically state hospitalization should be considered when severe pain suggests other diagnoses (abscess, infarction) or when patients are febrile 1.

Empiric Antibiotic Therapy (Age-Dependent):

For patients <35 years or sexually active:

• Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 5
• This covers N. gonorrhoeae and C. trachomatis 1, 5

For patients ≥35 years or with urinary tract instrumentation:

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 1, 5
• This covers enteric Gram-negative organisms 1, 5

For men who practice receptive anal intercourse:

• Consider enteric organism coverage with fluoroquinolones 5

Adjunctive Measures:

• Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 1, 3
• Intravenous broad-spectrum antibiotics if hospitalized for severe infection 6

Mandatory Re-evaluation:

• If no improvement within 3 days of antibiotic therapy, comprehensive re-evaluation is required 1
• Persistent swelling and tenderness after completing antibiotics mandates evaluation for:
  • Testicular tumor 1, 5
  • Abscess requiring drainage 1
  • Testicular infarction 1, 6
  • Tuberculosis or fungal infection (especially if immunocompromised) 1

Critical Clinical Pitfalls

• Never delay surgical consultation for imaging if clinical suspicion for torsion is high, as testicular viability is time-dependent 2, 3, 4
• The 7-day duration does NOT exclude torsion—intermittent torsion or recent complete torsion on a background of chronic pain is possible 2
• A hard testicle with fever suggests complicated infection that may require surgical intervention even if not torsion 1, 6
• Normal urinalysis does not exclude either torsion or epididymitis 2
• Ultrasound has significant false-negative rates—clinical judgment supersedes imaging 2

Sex Partner Management

If sexually transmitted epididymitis is confirmed or suspected, sex partners within the preceding 60 days should be evaluated and treated 1. The patient should abstain from sexual intercourse until both he and his partners complete therapy and are asymptomatic 1.