What is the appropriate treatment and evaluation for a male patient with swollen testicles?

Evaluation and Treatment of Swollen Testicles

Testicular torsion must be ruled out immediately in any patient with swollen testicles, as this is a surgical emergency requiring urgent urological consultation and exploration within hours to prevent testicular loss. 1

Immediate Diagnostic Approach

Critical First Steps

• Obtain focused history on pain onset: Abrupt, severe pain suggests torsion; gradual onset suggests epididymitis 1
• Assess Prehn sign: Pain NOT relieved with testicular elevation indicates torsion 1
• Order scrotal ultrasound with Doppler immediately if diagnosis is uncertain to differentiate torsion from other causes 1
• Check urinalysis to evaluate for infection, though normal urinalysis does NOT exclude torsion 1

Age-Based Differential Diagnosis

In patients under 35 years:

• Sexually transmitted epididymitis (Chlamydia trachomatis, Neisseria gonorrhoeae) is most common 2, 3
• Testicular torsion has bimodal distribution in neonates and postpubertal boys 1
• Obtain Gram stain of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 2
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 2

In patients over 35 years:

• Gram-negative enteric bacteria (particularly E. coli) causing epididymitis in context of UTI 3
• Associated with recent urinary instrumentation, surgery, or anatomical abnormalities 3
• Obtain urine culture and Gram stain for Gram-negative bacteria 3

Red Flags Requiring Immediate Action

• Scrotal ecchymosis or inability to identify testicular contours: Suggests testicular rupture requiring scrotal exploration and debridement 1
• Painless solid testicular mass: Pathognomonic for testicular tumor; obtain serum tumor markers (β-HCG, AFP, LDH) before any intervention 4, 1
• Tender nodule with blue discoloration on upper pole: Suggests torsion of testicular appendage, most common in prepubertal boys 1

Treatment Based on Diagnosis

For Epididymitis in Sexually Active Men Under 35 Years

Treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 2, 5, 6

Alternative regimen:

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 2

Adjunctive measures:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2

For Epididymitis in Men Over 35 Years (Non-Sexually Transmitted)

Treat with fluoroquinolone monotherapy (levofloxacin or ofloxacin) for enteric bacterial coverage 3

Supportive care:

• Bed rest and scrotal elevation until fever and inflammation subside 3
• NSAIDs for pain control 3

For Testicular Torsion

Immediate urological consultation and surgical exploration with detorsion is mandatory, with bilateral orchiopexy to prevent recurrence. 1

For Testicular Tumor

Inguinal orchiectomy is the primary treatment. 4, 1

• Discuss sperm banking before any therapeutic intervention that may compromise fertility 4
• Obtain serum tumor markers (β-HCG, AFP, LDH) before orchiectomy and repeat after to allow precise staging 4

Critical Follow-Up and Pitfalls

When to Reassess

• Reevaluate within 3 days if no improvement on antimicrobial therapy for epididymitis 2
• Persistent swelling and tenderness after completing antibiotics requires comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 2

Common Pitfalls to Avoid

• Do not give trial of antibiotics without ultrasound if testicular torsion cannot be clinically excluded 1
• Do not delay surgical consultation for suspected torsion—testicular viability decreases with each hour of delay 1
• In patients presenting with testicular discomfort or swelling suggestive of epididymitis/orchitis, a trial of antibiotics may be given, but persistent tenderness, swelling, or any palpable abnormality warrants ultrasound evaluation 4
• Hydrocele can mask underlying testicular tumors—if examination is limited by fluid, ultrasound is essential 7

Partner Management for STI-Related Epididymitis

• Partners from 60 days preceding symptom onset should be referred for evaluation and treatment 2
• Patients should avoid sexual intercourse until they and partners complete treatment and are symptom-free 2