Pain Radiating from Stomach to Left Testicle
This presentation demands immediate evaluation for testicular torsion, which can present with isolated abdominal pain in up to 22% of cases, particularly in adolescents and young adults—a missed diagnosis results in testicular loss in 81% of cases. 1, 2
Immediate Diagnostic Priorities
Rule Out Testicular Torsion First
Testicular torsion presenting as abdominal pain is a critical diagnostic pitfall that leads to delayed diagnosis (median 36 hours vs 5 hours when scrotal pain is present) and catastrophic testicular loss rates of 81% compared to only 4% when patients present with typical testicular pain 2
Young males (particularly ages 10-17 years) with acute abdominal pain require mandatory external genital examination—failure to examine the genitals initially led to misdiagnosis in 69% of testicular torsion cases presenting with abdominal pain 1, 2
The 6-8 hour window for testicular salvage begins from symptom onset, not from when scrotal symptoms develop, making early recognition of this atypical presentation life-or-testicle critical 3, 4
Key Clinical Features to Assess
Onset pattern: Abrupt onset of severe pain (developing within minutes) strongly suggests torsion, while gradual onset over hours to days suggests epididymitis 3, 5
Physical examination findings: Look for high-riding testicle, absent cremasteric reflex, negative Prehn sign (pain NOT relieved with testicular elevation), scrotal swelling or asymmetry 3, 6, 4
Age consideration: While testicular torsion has bimodal distribution (neonates and postpubertal boys), it remains possible in adults, though epididymitis becomes the most common cause of testicular pain in men over 25 years 3, 5
Diagnostic Algorithm
Step 1: Immediate Physical Examination
Examine both testicles for position, size, tenderness, and presence of cremasteric reflex—this takes 30 seconds and can prevent testicular loss 1, 2
Assess for scrotal swelling, redness, or asymmetry that may not be apparent to the patient focused on abdominal pain 6
Step 2: Risk Stratification
If high clinical suspicion for torsion exists (sudden onset, severe pain, abnormal testicular exam, young male), proceed directly to emergency urological consultation and surgical exploration WITHOUT waiting for imaging 3, 4
For intermediate suspicion, obtain urgent Duplex Doppler ultrasound with grayscale examination for "whirlpool sign" (96% sensitivity), color Doppler assessment of testicular perfusion (96-100% sensitivity), and comparison to contralateral testis 3
Step 3: Imaging Interpretation Caveats
False-negative Doppler studies occur in 30% or more of cases, particularly with partial torsion (<450 degrees), spontaneous detorsion, or early presentation 3, 5
Normal ultrasound does NOT exclude torsion if clinical suspicion remains high—proceed to surgical exploration when doubt exists 3
Power Doppler is more sensitive for detecting low-flow states and should be used, especially in younger patients 3
Differential Diagnosis by Likelihood
In Adolescents/Young Adults (Most Relevant to This Presentation)
Testicular torsion: Abrupt severe pain, may radiate to abdomen/groin, negative Prehn sign, absent cremasteric reflex, requires surgery within 6-8 hours 3, 6, 1
Epididymitis: Gradual onset over 1-2 days, may have urinary symptoms, positive Prehn sign, urinalysis may show pyuria (though normal urinalysis doesn't exclude it) 3, 5
Torsion of testicular appendage: Most common in prepubertal boys, may show "blue dot sign" (only 21% of cases), normal testicular perfusion with localized hyperemia 3
In Adults Over 25 Years
Epididymitis/epididymo-orchitis: Overwhelmingly most common (600,000 cases annually in US), gradual onset, enlarged epididymis with increased blood flow on Doppler 3, 5
Testicular torsion: Rare but still possible, cannot be excluded based on age alone 5
Segmental testicular infarction: Wedge-shaped avascular area on ultrasound, median age 37-38 years 3
Other Abdominal Causes to Consider
The broad differential for nonlocalized abdominal pain includes nephrolithiasis (which can radiate to testicle), inguinal hernia (can cause referred testicular pain), and various intra-abdominal pathologies 7, 8
CT abdomen/pelvis may be appropriate if testicular examination is completely normal and pain is clearly originating from abdomen, but only after testicular pathology is excluded 7
Management Based on Diagnosis
If Testicular Torsion Confirmed or Highly Suspected
Immediate urological consultation and emergency surgical exploration with detorsion, assessment of viability, and bilateral orchiopexy (to prevent contralateral torsion due to bell-clapper deformity present in 82% of cases) 3, 6
Do not delay surgery for imaging if clinical suspicion is high 4
If Epididymitis Diagnosed
Bed rest, scrotal elevation, NSAIDs for analgesia 3
Antibiotic therapy based on age and risk factors: sexually transmitted infection coverage (ceftriaxone plus doxycycline) in sexually active young men, or fluoroquinolone for enteric organisms in older men 3
If Imaging and Examination Normal but Pain Persists
Consider referred pain from ureteral stone, inguinal hernia, or other abdominal pathology 7, 8
Obtain urinalysis to evaluate for hematuria suggesting nephrolithiasis 5
Consider CT abdomen/pelvis if testicular pathology definitively excluded 7
Critical Clinical Pitfalls to Avoid
Never assume abdominal pain in a young male is purely abdominal without examining the testicles—this single error accounts for the majority of preventable testicular losses 1, 2
Do not be falsely reassured by normal urinalysis—it does not exclude either torsion or epididymitis 3, 5
Do not delay surgical exploration for imaging when clinical suspicion for torsion is high—imaging sensitivity is imperfect and time is testicle 3, 4
Remember that testicular torsion can spontaneously detorse and retorse, causing intermittent symptoms that may confuse the clinical picture 8
In cases initially overlooked, 81% resulted in gonadal loss, emphasizing that early surgical evaluation is paramount 2