From the Guidelines
The workup for testicular and abdominal pain in the emergency room should begin with a thorough history and physical examination, focusing on onset, duration, severity, and radiation of pain, and immediate evaluation is crucial to rule out testicular torsion, which requires surgical intervention within 6 hours to save the testicle, as recommended by the most recent guidelines 1.
Key Components of the Workup
- A thorough history and physical examination to identify the onset, duration, severity, and radiation of pain
- Laboratory tests including urinalysis, complete blood count, and possibly liver and pancreatic enzymes if abdominal pathology is suspected
- Imaging studies starting with testicular ultrasound with Doppler to evaluate blood flow and identify torsion, epididymitis, orchitis, or masses
- Abdominal imaging may include ultrasound or CT scan depending on the suspected diagnosis
Importance of Prompt Evaluation
Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss in cases of testicular torsion, as highlighted in the 2024 update of the ACR Appropriateness Criteria for acute onset of scrotal pain 1.
Diagnostic Considerations
Diagnostic considerations include testicular torsion, torsion of testicular appendage, epididymoorchitis, epididymitis, idiopathic scrotal edema, hydrocele, inflammation of the tunica vaginalis, trauma, testicular tumors, epididymal cysts, Fournier gangrene, scrotal abscess, and strangulated inguinal hernia, with torsion of a testicular appendage being the most common etiology in prepubertal boys 1.
Imaging and Treatment
Imaging studies are essential, and treatment will depend on the diagnosis, with surgical detorsion for torsion, antibiotics for infection, or appropriate management for other identified conditions, and pain management should be provided with appropriate analgesics such as NSAIDs or opioids, as supported by the guidelines 1.
From the Research
Work-up for Testicular and Abdominal Pain in Emergency Room
- The work-up for testicular and abdominal pain in the emergency room involves a thorough history, physical examination, and diagnostic tests to determine the underlying cause of the pain.
- According to 2, epididymo-orchitis is a common cause of testicular pain and swelling, and the most common pathogens in men under 35 are N gonorrhoeae and C trachomatis, while E coli is the most common cause in men over 35.
- The physical examination should include an assessment of the testes, epididymis, and abdomen, as well as a digital rectal exam to check for bladder outflow obstruction, benign prostatic hyperplasia, prostate cancer, constipation, and prostatitis 2.
- Testicular torsion is a surgical emergency that requires prompt diagnosis and treatment, and it is essential to exclude torsion in all patients who present with acute scrotum 3, 4.
- Ultrasound of the scrotum plays a crucial role in assessing acute scrotal conditions, including testicular torsion and epididymo-orchitis, and can help guide management decisions 5.
- Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, can help guide therapy for epididymo-orchitis 6.
Diagnostic Tests
- Ultrasound of the scrotum is a valuable diagnostic tool for assessing acute scrotal conditions, including testicular torsion and epididymo-orchitis 5.
- Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, can help guide therapy for epididymo-orchitis 6.
- Imaging studies, such as computed tomography (CT) or magnetic resonance imaging (MRI), may be necessary in some cases to evaluate the abdomen and rule out other causes of pain 2.
Management
- Patients with suspected testicular torsion should be referred to secondary care immediately for surgical evaluation and treatment 2, 3, 4.
- Patients with epididymo-orchitis should be treated with empirical antibiotics, such as ceftriaxone and doxycycline, or ofloxacin or levofloxacin, depending on the suspected pathogen 2, 6.
- Patients who are in severe pain or systemically unwell should be referred for analgesia, IV antibiotics, and hydration 2.