From the Guidelines
For a 58-year-old male with right testicle pain that is now improving, the most appropriate initial imaging is a scrotal ultrasound, as recommended by the American College of Radiology 1. The patient's symptoms, although improving, necessitate a thorough evaluation to rule out serious conditions such as testicular torsion, epididymitis, orchitis, or testicular cancer. According to the ACR Appropriateness Criteria, a scrotal ultrasound is usually appropriate as the initial imaging for acute onset of scrotal pain without trauma or antecedent mass in an adult 1. Some key points to consider in the management of this patient include:
- Ordering a scrotal ultrasound to evaluate the testicles and surrounding structures
- Prescribing Naproxen 500 mg twice daily to reduce inflammation and alleviate pain
- Scheduling a follow-up appointment in two weeks to assess symptom improvement and review ultrasound results
- Advising the patient to seek immediate medical attention if pain worsens, swelling increases, or if he develops fever, as these could indicate a worsening condition requiring urgent intervention The European Association of Urology guidelines on urological infections provide a framework for managing acute scrotal pain and swelling in adult males, including the use of antibiotics and scrotal ultrasound examination 1. However, the most recent and highest quality study, the ACR Appropriateness Criteria, prioritizes scrotal ultrasound as the initial imaging modality 1. Therefore, the patient should undergo a scrotal ultrasound as the initial imaging study to guide further management, and the follow-up appointment will be crucial in determining the next steps based on the ultrasound results and the patient's clinical progress.
From the Research
Diagnosis and Treatment
- The patient's symptoms of right testicle pain and inflammation in the bottom part of the testicle, which has diminished, suggest the possibility of orchitis or a testicular tumor 2.
- Ordering a scrotal US is a suitable diagnostic approach, as ultrasound is the imaging modality of choice for evaluating the scrotum due to its high resolution, Doppler capabilities, and lack of ionizing radiation 3.
- The majority of scrotal ultrasounds performed for scrotal or testicular pain reveal normal or benign findings, with only a low percentage demonstrating a finding that necessitates urgent or emergent surgery 4.
Medication
- Naproxen 500 mg BID has been shown to be effective in reducing pain and inflammation in various conditions, including osteoarthritis of the knee 5 and ankle sprain 6.
- However, the efficacy and safety of naproxen for testicular pain and inflammation specifically are not well-established in the provided studies.
- It is worth noting that naproxen as needed may have a better safety profile and lower total drug use compared to twice-daily dosing 6.
Follow-up
- Scheduling a follow-up appointment in two weeks to reassess the patient's symptoms and review the ultrasound results is a reasonable approach, as it allows for monitoring of the patient's condition and adjustment of treatment as needed.
- Follow-up Doppler US examination may be valuable in differentiating between orchitis and testicular tumor, as it can help identify persistent high velocity values in patients with tumors and normalization of velocity values in patients with orchitis 2.