What is the appropriate treatment and management for a male patient of any age with a swollen testicle, potentially caused by conditions such as testicular torsion, bacterial epididymitis, or viral orchitis?

Swollen Testicle: Diagnosis and Management

Immediate Priority: Rule Out Testicular Torsion

Any patient presenting with a swollen testicle must be evaluated emergently to exclude testicular torsion, as this is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular loss. 1

Critical Time-Sensitive Assessment

• Onset of symptoms: Abrupt, severe pain strongly suggests torsion, while gradual onset over hours to days suggests epididymitis 1, 2
• Age matters significantly: Torsion has a bimodal distribution with peaks in neonates and postpubertal boys, but can occur at any age including adults 1, 3
• Pain characteristics: Severe, unrelenting pain with nausea/vomiting suggests torsion 4, 5
• Prehn sign: Pain relief with testicular elevation suggests epididymitis rather than torsion 2

Immediate Diagnostic Workup

Order urgent Duplex Doppler ultrasound immediately unless clinical suspicion for torsion is so high that imaging would delay surgery 1, 5

Key ultrasound findings for torsion: 1

• Decreased or absent testicular blood flow compared to contralateral side
• "Whirlpool sign" of twisted spermatic cord (96% sensitivity)
• Enlarged, heterogeneous, hypoechoic testis
• Ipsilateral hydrocele and scrotal wall thickening

Critical pitfall: Doppler ultrasound has false-negative rates up to 30%, particularly with partial torsion or spontaneous detorsion 1, 2. If clinical suspicion remains high despite normal Doppler, proceed immediately to surgical exploration. 1

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Management Algorithm Based on Diagnosis

If Testicular Torsion Confirmed or Highly Suspected

Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset 1, 5, 6

• Do not delay surgery for imaging if clinical suspicion is high 6
• Testicular salvage rates decline dramatically after 6 hours 4, 5
• Surgery involves detorsion, assessment of viability, and bilateral orchiopexy 1

If Epididymitis/Epididymo-orchitis Diagnosed

This is the most common cause of testicular pain and swelling in adults, particularly those over 35 years 1, 2, 7

Ultrasound findings confirming epididymitis: 1

• Enlarged epididymis with increased blood flow on Doppler
• Scrotal wall thickening
• May have hydrocele

Age-stratified antibiotic treatment:

For men under 35 years (likely STI-related - C. trachomatis or N. gonorrhoeae): 8, 7

• Ceftriaxone 250 mg IM single dose 8, 9
• PLUS Doxycycline 100 mg orally twice daily for 10 days 8, 10

For men over 35 years (likely enteric organisms - E. coli): 8, 7

• Ofloxacin 300 mg orally twice daily for 10 days 8
• OR Levofloxacin 500 mg orally once daily for 10 days 8

Adjunctive measures for all epididymitis patients: 8

• Bed rest until fever and inflammation subside
• Scrotal elevation
• Analgesics

Hospitalization criteria: 8

• Severe pain suggesting alternative diagnosis
• Fever or systemic illness
• Concern for patient compliance with oral antibiotics

Critical follow-up: Failure to improve within 3 days requires reevaluation of diagnosis and consideration of abscess, tumor, or testicular torsion 8

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Additional Diagnostic Considerations

Torsion of Testicular Appendage

• Most common cause of testicular pain in prepubertal boys 1
• "Blue dot sign" visible in only 21% of cases 1
• Ultrasound shows normal testicular perfusion with localized hyperemia 1
• Usually managed conservatively without surgery 5

Orchitis (Viral)

• Often associated with mumps or other viral infections 7
• Bilateral involvement more common than with bacterial epididymitis 7
• Supportive care with analgesics and scrotal support

Testicular Tumor

• Consider in any patient with persistent swelling after treatment 8
• Germ cell tumors constitute 95% of testicular tumors 2
• Requires ultrasound evaluation and tumor markers

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Common Pitfalls to Avoid

Never assume epididymitis based on age alone - testicular torsion can occur in adults, including men in their 50s 3

Never rely solely on physical examination - there is significant overlap in clinical presentation between torsion and epididymitis 1, 2, 3

Never delay surgical exploration if torsion cannot be excluded - when in doubt, explore surgically rather than risk testicular loss 6

Never ignore persistent symptoms after antibiotic treatment - this warrants comprehensive reevaluation for tumor, abscess, or missed torsion 8

Never forget to treat sexual partners - for STI-related epididymitis, partners within 60 days of symptom onset require evaluation and treatment 8