What is the appropriate management for a patient with sudden onset unilateral testicle pain?

Management of Sudden Onset Unilateral Testicular Pain

Treat sudden onset unilateral testicular pain as testicular torsion until proven otherwise, and obtain immediate urological consultation without delay—testicular viability is compromised if not surgically treated within 6-8 hours of symptom onset. 1, 2

Immediate Actions

Do not delay surgical consultation for imaging when clinical suspicion is high, as this risks testicular loss. 2 The critical management steps are:

• Activate emergency urological consultation immediately upon presentation of acute unilateral testicular pain 1, 2
• Obtain Duplex Doppler ultrasound only if it will not delay surgical exploration (sensitivity 69-96.8%, specificity 87-100%) 1
• Proceed directly to surgical exploration if clinical suspicion is high, regardless of imaging availability 1, 2

Time-Critical Window

The salvage rate for testicular torsion depends entirely on time to intervention:

• 6-8 hours: Critical window before permanent ischemic damage occurs 1, 2
• Within 12 hours: Better surgical outcomes when intervention occurs in this timeframe 1
• Beyond 12 hours: Significantly increased risk of testicular loss 1

Clinical Assessment to Guide Urgency

High-Risk Features for Torsion (Immediate Surgical Exploration)

• Sudden onset of severe scrotal pain (most characteristic feature) 1, 2
• Negative Prehn sign (pain NOT relieved with testicular elevation) 1, 3
• High-riding, firm, tender testicle 4
• Absent cremasteric reflex (though not completely reliable) 5
• Nausea and vomiting 1, 4
• Age 12-18 years or neonatal period (bimodal distribution) 1, 2

Features Suggesting Epididymitis (Still Requires Urgent Evaluation)

• Gradual onset of pain over hours to days 1, 2
• Positive Prehn sign (pain relief with testicular elevation) 2, 3
• Dysuria or urethral discharge 1
• Fever (more common than in torsion) 3
• Age >25 years or sexually active 1, 3

Diagnostic Imaging Protocol (When Appropriate)

Only obtain ultrasound if it will not delay surgical consultation and clinical suspicion is intermediate. 1 When performed, the study must include:

Essential Ultrasound Components

• Grayscale examination: Look for "whirlpool sign" of twisted spermatic cord (96% sensitivity), enlarged heterogeneous testis, ipsilateral hydrocele 1, 6
• Color Doppler assessment: Decreased or absent blood flow to affected testicle compared to contralateral side 1, 6
• Power Doppler: More sensitive for low-flow states, particularly useful in prepubertal boys 1
• Spectral Doppler analysis: Assess upper, mid, and lower poles for regional flow variations 1

Critical Ultrasound Pitfalls

• False-negative rate of 30% or more, particularly with partial torsion, spontaneous detorsion, or early presentation 1, 3
• Prepubertal boys normally have reduced intratesticular blood flow, which can mimic torsion 1
• Normal ultrasound does NOT exclude torsion—proceed to surgical exploration if clinical suspicion remains high 1, 5
• Partial torsion may show persistent arterial flow because venous obstruction occurs first 1

Definitive Management

Surgical Treatment (Testicular Torsion)

Immediate surgical exploration with detorsion and bilateral orchiopexy is the definitive treatment. 1 The procedure includes:

• Inguinal or scrotal exploration with detorsion of affected testis 1
• Assessment of testicular viability after detorsion 1
• Bilateral orchiopexy to prevent contralateral torsion (82% have bell-clapper deformity) 1, 4
• Post-operative care: bed rest, scrotal elevation, analgesics 1

Manual Detorsion (Temporizing Measure Only)

Manual detorsion can be attempted while awaiting surgical intervention, but should never replace definitive surgical treatment 6, 5:

• Ultrasound guidance may improve success rate 6
• Most testes rotate medially ("opening the book" technique) 5
• May fail due to patient discomfort, incomplete torsion, or atypical rotation direction 6

Medical Management (Epididymitis)

If epididymitis is confirmed and torsion excluded 3:

• Sexually active <35 years: Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg PO twice daily × 10 days 3
• Age >35 years or enteric organisms suspected: Ofloxacin 300 mg PO twice daily × 10 days OR levofloxacino 500 mg PO once daily × 10 days 3
• Bed rest, scrotal elevation, analgesics 1, 3
• Reevaluate if no improvement within 3 days 3

Age-Stratified Differential Diagnosis

Understanding age-related patterns helps risk stratification but should never delay treatment:

• Neonates and 12-18 years: Testicular torsion most common (bimodal peak) 1, 2
• Prepubertal boys: Torsion of testicular appendage most common (look for "blue dot sign" in 21% of cases) 1, 2
• Adults >25 years: Epididymitis most common (600,000 cases annually in US) 1, 3
• Adults >35 years: Testicular torsion rare 1

Common Pitfalls to Avoid

• Never start antibiotics empirically when torsion is suspected—this delays correct diagnosis and treatment 2
• Never rely solely on cremasteric reflex presence or absence 5
• Never delay for advanced imaging (MRI, CT) when torsion is suspected 1, 2
• Never dismiss the diagnosis because pain is not severe—rare cases of torsion present with minimal pain 7
• Never assume trauma history excludes torsion—trauma can be a red herring, and progressive worsening pain suggests torsion 2
• Consider testicular malignancy in differential if pain persists after completing antimicrobial treatment for presumed epididymitis 3, 8