What could be causing my intermittent left testicular pain that comes and goes for one week?

Intermittent Left Testicular Pain for One Week

Your intermittent left testicular pain lasting one week requires urgent evaluation to rule out testicular torsion—particularly intermittent (stuttering) torsion—which is a surgical emergency that can lead to testicular loss if not treated within 6-8 hours of an acute episode. 1

Immediate Assessment Required

You need urgent Duplex Doppler ultrasound of the scrotum to evaluate testicular blood flow and rule out torsion. 1 The key clinical features that distinguish between causes include:

• Sudden, severe pain with negative Prehn sign (pain NOT relieved by elevating the testicle) suggests testicular torsion 1, 2
• Gradual onset pain with positive Prehn sign (pain relieved by elevation) suggests epididymitis 1, 2
• Intermittent episodes of sharp pain with pain-free intervals strongly suggest intermittent (stuttering) testicular torsion 3

Most Likely Diagnoses Based on Your Pattern

Intermittent Testicular Torsion (High Priority)

This is the most concerning diagnosis given your "comes and goes" pattern. 3 Intermittent torsion presents with:

• Acute, sharp testicular pain episodes separated by symptom-free intervals 3
• Physical exam may show horizontal testis position, anteriorly located epididymis, or bulky spermatic cord 3
• Requires elective bilateral orchiopexy even between episodes to prevent complete torsion and testicular loss 3

Epididymitis (Most Common in Adults)

This accounts for approximately 600,000 cases annually in the United States and is the most common cause of testicular pain in adults. 1 Features include:

• More gradual pain onset over hours to days 1
• May have abnormal urinalysis (though normal urinalysis doesn't exclude it) 1
• Ultrasound shows enlarged epididymis with increased blood flow on Doppler 1, 2

Varicocele

Can cause intermittent dull, aching, or throbbing testicular pain that worsens with activity. 4 However, this is typically less acute than your presentation suggests.

Critical Diagnostic Steps

Duplex Doppler ultrasound must include: 1

• Grayscale examination to assess testicular size, homogeneity, and look for the "whirlpool sign" of twisted spermatic cord 1
• Color/Power Doppler to compare blood flow between both testicles 1
• Spectral Doppler analysis of upper, mid, and lower poles of each testicle 1

Important caveat: Ultrasound has 69-96.8% sensitivity for torsion, meaning false negatives occur in up to 30% of cases, particularly with partial or intermittent torsion. 1 If clinical suspicion remains high despite normal imaging, immediate urological consultation and surgical exploration should proceed. 1

Management Algorithm

If testicular torsion is suspected or confirmed:

• Immediate urological consultation for surgical exploration within 6-8 hours 1, 2
• Surgical outcomes are significantly better when surgery occurs within this critical window 1
• Bilateral orchiopexy is performed to prevent future episodes and contralateral torsion 1

If epididymitis is diagnosed:

• Bed rest, scrotal elevation, and analgesics 1
• Appropriate antibiotic therapy based on age and risk factors 1

If intermittent torsion is diagnosed (even between episodes):

• Elective bilateral orchiopexy is recommended to prevent complete torsion 3
• Do not wait for an acute episode, as testicular salvage rates drop dramatically with delayed treatment 3

Critical Pitfalls to Avoid

• Never dismiss intermittent testicular pain as benign without proper evaluation—this pattern is characteristic of intermittent torsion 3
• Do not delay surgical consultation for imaging when clinical suspicion for torsion is high 2
• Age is not protective—while torsion has a bimodal distribution peaking in neonates and adolescents, it can occur in adults 1
• Normal urinalysis does not exclude torsion 1
• Point-of-care handheld Doppler by emergency physicians has 97.8% specificity for ruling out torsion and can be used for rapid triage 5

Bottom line: Seek urgent medical evaluation today. Your "comes and goes" pattern over one week is concerning for intermittent torsion, which requires surgical intervention even between episodes to prevent catastrophic testicular loss during a future complete torsion event.