What are the possible causes and treatments for testicle pain?

Testicular Pain: Causes and Management

Immediate Priority: Rule Out Testicular Torsion

Any acute testicular pain must be treated as a surgical emergency until testicular torsion is excluded, as testicular viability is compromised if not treated within 6-8 hours of symptom onset. 1

When to Suspect Torsion (Requires Immediate Urological Consultation)

• Sudden onset of severe pain with rapid progression 1
• Negative Prehn sign (pain NOT relieved when testicle is elevated) 1
• Firm, tender testicle on examination 2
• More common in adolescents and young adults (bimodal distribution: neonates and postpubertal boys) 1
• Normal urinalysis does NOT exclude torsion 1

Emergency Diagnostic Approach

• Duplex Doppler ultrasound is first-line imaging (sensitivity 69-96.8%, specificity 87-100%) 1
• Key ultrasound findings for torsion: decreased/absent blood flow, "whirlpool sign" of twisted spermatic cord, enlarged heterogeneous testis 1
• Critical pitfall: False-negative Doppler occurs in up to 30% of cases, particularly with partial torsion or early presentation 1
• If clinical suspicion is high, proceed directly to surgical exploration without waiting for imaging 2

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Common Causes of Testicular Pain by Age

Adults (Most Common: Epididymitis)

Epididymitis/epididymo-orchitis accounts for approximately 600,000 cases annually in the United States and is the most common cause in adults. 1

Clinical Features

• Gradual onset of pain (vs. sudden in torsion) 1
• Positive Prehn sign (pain relieved with testicular elevation) 2
• May have fever, dysuria, urethral discharge 3
• Ultrasound shows enlarged epididymis with increased blood flow on Doppler 1

Treatment for Epididymitis

For sexually active men <35 years or suspected STI:

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 3

For men ≥35 years or enteric organism suspected:

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 3

Adjunctive measures: Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 3

Critical Follow-Up

• Failure to improve within 3 days requires re-evaluation of diagnosis and therapy 3
• Persistent swelling after completing antibiotics mandates evaluation for tumor, abscess, infarction, tuberculosis, or fungal infection 3, 4

Prepubertal Boys (Most Common: Torsion of Testicular Appendage)

• Torsion of testicular appendage is most common in this age group 1
• May present with "blue dot sign" (visible through skin in 21% of cases) 2
• Ultrasound shows normal testicular perfusion with localized hyperemia near appendage 1
• Generally managed conservatively with analgesics and observation 2

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Severe or Complicated Presentations

Red Flags Requiring Hospitalization

If patient presents with severe pain, hard testicle, and new-onset fever lasting >3-7 days, consider complicated epididymo-orchitis with abscess/infarction or delayed testicular torsion. 4

Management Algorithm for Severe Cases

1. Immediate urological consultation for surgical exploration if ultrasound shows absent/decreased flow 4
2. Hospitalization with IV broad-spectrum antibiotics for severe infection 4
3. Surgical exploration may be needed to assess viability, remove necrotic tissue, or drain abscess 4
4. Mandatory re-evaluation if no improvement within 3 days 4

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Other Important Differential Diagnoses

Segmental Testicular Infarction

• Presents as wedge-shaped avascular area on ultrasound 1
• Median age 37-38 years 1
• May require follow-up imaging in 6-8 weeks with tumor markers to exclude malignancy 1

Acute Idiopathic Scrotal Edema

• Rare, self-limiting condition primarily in prepubertal boys 1
• Marked scrotal wall thickening with minimal pain 1
• Normal testicular vascularity on Doppler 1
• Diagnosis of exclusion 1

Chronic Testicular Pain (>3 months duration)

• Often no identifiable cause in approximately 50% of cases 5, 6
• Consider neuropathic causes (genitofemoral/ilioinguinal nerve entrapment) 6
• Consider musculoskeletal causes remote to testicle 6
• Initial conservative management: NSAIDs combined with antibiotics (even without identified infection) 5
• Referral to multidisciplinary pain clinic before considering opiates 5
• Surgical options (microsurgical denervation, epididymectomy) reserved for refractory cases 7
• Orchiectomy only when all conservative measures fail and pain severely diminishes quality of life 5, 7

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Critical Clinical Pitfalls to Avoid

• Never delay surgical consultation for imaging when torsion is clinically suspected 2
• Trauma history can be misleading—progressive worsening pain with systemic symptoms suggests torsion, not simple injury 2
• Normal Doppler does NOT exclude torsion—if clinical suspicion remains high, proceed to surgical exploration 1
• Starting antibiotics empirically for suspected torsion delays correct diagnosis and risks testicular loss 2
• Significant overlap exists in clinical presentation between torsion, epididymitis, and appendage torsion 1
• Consider occult vasculitis or malignancy in adults with testicular pain and systemic symptoms 8