What is the appropriate management for a male patient with acute left scrotal pain?

Management of Acute Left Scrotal Pain

Acute left scrotal pain must be treated as testicular torsion until proven otherwise, requiring immediate urological consultation and urgent Doppler ultrasound evaluation within 6-8 hours of symptom onset to prevent testicular loss. 1

Immediate Clinical Assessment

The critical first step is determining the timing and character of pain onset:

• Abrupt, severe onset strongly suggests testicular torsion, which is a surgical emergency 1
• Gradual onset is more consistent with epididymitis/epididymo-orchitis 1
• Duration of symptoms is critical—testicular viability becomes compromised after 6-8 hours, with better surgical outcomes when intervention occurs within 12 hours 1

Key physical examination findings to assess:

• Negative Prehn sign (pain NOT relieved with testicular elevation) indicates torsion 1
• Positive Prehn sign (pain relieved with elevation) suggests epididymitis
• Presence of cremasteric reflex (its absence suggests torsion)
• Testicular lie and position

Risk Stratification by Age

Age significantly influences the differential diagnosis:

• Adolescents and postpubertal boys: Testicular torsion is most common, with a bimodal peak in this age group 1
• Prepubertal boys: Torsion of testicular appendage is most common 1
• Adults over 25 years: Epididymitis/epididymo-orchitis is overwhelmingly most common, representing approximately 600,000 cases annually in the United States 1
• Adults over 35 years: Testicular torsion becomes rare 1

Diagnostic Imaging Protocol

Duplex Doppler ultrasound is the first-line imaging modality with sensitivity of 69-96.8% and specificity of 87-100% 1

The ultrasound examination must include:

• Grayscale assessment looking for the "whirlpool sign" of twisted spermatic cord (96% sensitivity), enlarged heterogeneous testis, ipsilateral hydrocele, and scrotal wall thickening 1
• Color Doppler evaluation comparing testicular perfusion to the contralateral side (sensitivity 96-100%) 1
• Power Doppler is particularly useful for prepubertal testes with normally slow flow 1
• Spectral Doppler analysis of upper, mid, and lower poles to detect regional flow variations 1

Critical Imaging Pitfalls

Be aware that false-negative Doppler evaluations occur in up to 30% of cases, particularly with:

• Partial torsion where arterial flow may persist because venous obstruction occurs first 1
• Spontaneous detorsion 1
• Early presentation within the first few hours when the testis may appear normal 1
• Prepubertal boys who normally have reduced intratesticular blood flow, potentially leading to false-positive interpretations 1

Management Algorithm Based on Clinical Suspicion

High Clinical Suspicion for Torsion

Proceed directly to immediate urological consultation and surgical exploration without waiting for imaging if clinical presentation is classic (sudden severe pain, negative Prehn sign, absent cremasteric reflex) 1

• Imaging should never delay surgical intervention when suspicion is high 1
• Surgical detorsion must occur within 6-8 hours to prevent permanent ischemic damage 1
• Bilateral orchiopexy is performed during surgery to prevent contralateral torsion (82% of patients have Bell clapper deformity) 1

Intermediate Clinical Suspicion (TWIST Score 1-5)

Obtain urgent Duplex Doppler ultrasound with complete grayscale, color Doppler, and power Doppler evaluation 1

If ultrasound shows:

• Decreased or absent testicular blood flow: Immediate surgical exploration 1
• Whirlpool sign present: Immediate surgical exploration 1
• Normal flow but high clinical suspicion persists: Proceed to surgical exploration anyway, as false-negatives occur 1

Confirmed Epididymitis/Epididymo-orchitis

Ultrasound findings include enlarged epididymis with increased blood flow on Doppler, scrotal wall thickening, and possible hydrocele 1

Management includes:

• Bed rest and scrotal elevation 1
• Analgesics 1
• Appropriate antibiotic therapy based on age and risk factors 1

In the study by Karmazyn et al., epididymitis was the most common diagnosis in 43% of pediatric cases presenting with acute scrotal pain 2

Torsion of Testicular Appendage

Most common in prepubertal boys, with normal testicular perfusion but localized hyperemia near the appendage 1

• The "blue dot sign" is pathognomonic but only seen in 21% of cases 1
• This represented 40.6% of cases in one pediatric series 2
• Generally managed conservatively with analgesics and observation, though 88.5% underwent surgery in one series 2

Additional Differential Considerations

Segmental testicular infarction: Classic wedge-shaped avascular area on ultrasound, may also appear as round lesions with variable Doppler flow 1

Acute idiopathic scrotal edema: Rare, self-limiting condition with marked scrotal wall thickening, usually painless or minimally painful, diagnosis of exclusion 1

Thrombosed varicocele: Rare cause presenting with pain out of proportion to clinical findings; patients not responding to medical therapy may require varicocelectomy 3

Tension hydrocele: Extremely rare but can cause compromised testicular perfusion requiring emergent drainage 4

Key Clinical Principle

When clinical suspicion for testicular torsion remains high despite normal or equivocal imaging, immediate urological consultation and surgical exploration should proceed because the consequences of missing torsion (testicular loss, infertility) far outweigh the risks of negative exploration 1. The significant overlap in clinical presentations between different causes of acute scrotal pain makes diagnosis challenging, and surgical exploration remains mandatory when imaging does not provide a clear diagnosis 1, 5.