What are the appropriate steps for managing sudden severe right testicular pain?

Management of Sudden Severe Right Testicular Pain

Treat sudden severe right testicular pain as testicular torsion until proven otherwise and obtain immediate urological consultation for surgical exploration within 6-8 hours of symptom onset to prevent permanent testicular loss. 1, 2

Immediate Clinical Assessment

Evaluate the following key distinguishing features to risk-stratify the patient:

• Onset pattern: Abrupt, sudden onset of severe pain strongly suggests testicular torsion, while gradual onset over hours to days points toward epididymitis 1, 2
• Physical examination findings for torsion: High-riding testicle, absent cremasteric reflex, and negative Prehn sign (pain NOT relieved by testicular elevation) 1, 2, 3
• Associated symptoms: Nausea and vomiting are common with torsion 2, 3
• Age consideration: Testicular torsion has a bimodal distribution with peaks in neonates and postpubertal boys, though it can occur at any age 1

Critical Time Window

Surgical intervention must occur within 6-8 hours of symptom onset to prevent permanent ischemic damage and testicular loss. 1, 2, 3 Testicular salvage rates decline dramatically after this window, and delays may necessitate orchiectomy 3.

Diagnostic Algorithm

High Clinical Suspicion (Sudden Severe Pain + Physical Exam Findings)

Proceed directly to emergency surgical exploration without waiting for imaging studies. 1, 2 Do not delay definitive treatment to obtain ultrasound when clinical presentation strongly suggests torsion 3.

Intermediate Clinical Suspicion

Obtain urgent Duplex Doppler ultrasound with the following protocol 1, 2:

• Grayscale examination: Look for the "whirlpool sign" of twisted spermatic cord (96% sensitivity), enlarged heterogeneous testis appearing hypoechoic, ipsilateral hydrocele, and scrotal wall thickening 1
• Color/Power Doppler assessment: Evaluate for decreased or absent testicular blood flow compared to the contralateral side (96-100% sensitivity) 1, 2
• Power Doppler: Particularly useful in prepubertal patients who normally have reduced intratesticular blood flow 1, 2
• Use contralateral testicle as internal control for comparison 1

Critical Diagnostic Pitfalls

Be aware that ultrasound has important limitations:

• False-negative rate of up to 30%, particularly with partial torsion, spontaneous detorsion, or early presentation 1
• Sensitivity ranges from 69-96.8%, meaning normal Doppler does NOT exclude torsion when clinical suspicion remains high 1, 2
• Partial torsion may show diminished but present arterial flow because venous obstruction occurs first, making diagnosis challenging 1

When clinical suspicion remains high despite normal or equivocal imaging, proceed immediately to surgical exploration. 1, 2

Differential Diagnosis to Consider

Epididymitis/Epididymo-orchitis

• Gradual onset of pain over hours to days 1, 2
• May have fever, dysuria, or urethral discharge 2
• In men under 35 years: Usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae 2, 4
• In men over 35 years: Usually caused by gram-negative enteric organisms from UTI 2, 4
• Ultrasound shows enlarged epididymis with increased blood flow on Doppler 1, 2

Torsion of Testicular Appendage

• Most common cause of testicular pain in prepubertal boys 1
• "Blue dot sign" is pathognomonic but only seen in 21% of cases 1
• Normal testicular perfusion with localized hyperemia near the appendage 1

Management Based on Diagnosis

Confirmed or Highly Suspected Testicular Torsion

• Immediate urological consultation and surgical exploration 1, 2
• Surgical procedure includes detorsion, assessment of testicular viability, and bilateral orchiopexy to prevent contralateral torsion (82% of patients have Bell clapper deformity predisposing to bilateral risk) 1
• Post-operative care: Bed rest, scrotal elevation, and analgesics 1

Confirmed Epididymitis

Empiric antibiotic therapy based on age and risk factors 2, 4:

• Men under 35 years or sexually active: Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg orally twice daily for 10 days 4
• Men over 35 years: Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 4
• Supportive care: Bed rest, scrotal elevation, and analgesics 1, 2
• Diagnostic workup: Gram stain of urethral exudate, NAAT for N. gonorrhoeae and C. trachomatis, urinalysis, urine culture 2, 4

Key Clinical Caveat

Testicular torsion can present without severe pain in rare cases, which may lead to delayed diagnosis 5. Maintain a high index of suspicion even when pain is not as severe as typically described, particularly in adolescents 5.