What is the best course of action for a patient with a swollen and painful testicle, who has been administered Tylenol (acetaminophen) 650mg, and is in need of urgent evaluation for potential conditions such as testicular torsion, epididymitis, or orchitis?

Immediate Surgical Emergency: Urgent Urological Consultation Required

This patient requires immediate urological consultation and urgent surgical exploration for suspected testicular torsion, as testicular viability is compromised if not treated within 6-8 hours of symptom onset. 1

Critical Time-Sensitive Actions

Immediate Steps (Do Not Delay)

• Call urology NOW - do not wait for imaging if clinical suspicion is high 1
• Continue pain management while awaiting surgical evaluation 1
• Keep patient NPO (nothing by mouth) in preparation for potential emergency surgery 1
• Obtain IV access if not already established 1

Clinical Assessment to Perform Immediately

• Onset and character of pain: Testicular torsion presents with abrupt, severe scrotal pain, while epididymitis has gradual onset 1
• Prehn sign: Pain that is NOT relieved with testicular elevation suggests torsion (negative Prehn sign) 1
• Cremasteric reflex: Absent cremasteric reflex is highly suggestive of torsion 2
• Testicular position: Look for a high-riding testicle 2
• Associated symptoms: Nausea and vomiting are common with torsion 3, 4

Diagnostic Approach

If High Clinical Suspicion for Torsion

Proceed directly to surgical exploration without imaging - do not delay surgery to obtain ultrasound if clinical presentation strongly suggests torsion 1, 2

If Intermediate Clinical Suspicion

• Urgent Duplex Doppler ultrasound with the following protocol 1:
  • Grayscale examination for "whirlpool sign" (96% sensitivity) 1
  • Color Doppler assessment of testicular perfusion (96-100% sensitivity) 1
  • Power Doppler for detecting low-flow states 1
  • Compare to contralateral testicle as internal control 1

Critical Imaging Pitfall

False-negative Doppler occurs in 30% or more of cases, particularly with partial torsion or spontaneous detorsion 1, 5. If clinical suspicion remains high despite normal ultrasound, proceed immediately to surgical exploration 1, 5

Differential Diagnosis by Age and Presentation

Most Likely Diagnoses

• Testicular torsion (surgical emergency): Abrupt severe pain, negative Prehn sign, absent cremasteric reflex, high-riding testicle 1, 2
• Epididymitis/epididymo-orchitis: Gradual onset pain, may have abnormal urinalysis (though normal UA doesn't exclude it), positive Prehn sign 1
• Torsion of testicular appendage: Most common in prepubertal boys, may see "blue dot sign" (only 21% of cases) 1

Important Consideration

Epididymitis can predispose to subsequent testicular torsion due to testicular enlargement and inflammation 6. Even if epididymitis is initially diagnosed, maintain high suspicion for torsion if symptoms worsen or change character 6

Surgical Management

If Torsion Confirmed or Highly Suspected

• Immediate surgical exploration and detorsion within 6-8 hours 1, 2
• Bilateral orchiopexy to prevent contralateral torsion (Bell-clapper deformity present in 82% of cases) 5
• Testicular salvage rates decline dramatically after 6-8 hours, with permanent ischemic damage likely 1, 2

Post-Operative Care

• Bed rest, scrotal elevation, and analgesics until inflammation subsides 1

Key Clinical Pitfalls to Avoid

1. Never delay surgical exploration for imaging when clinical suspicion is high 1, 2
2. Do not rely solely on ultrasound - significant overlap exists between torsion and epididymitis presentations 1
3. Do not assume adult age excludes torsion - while less common in adults, it can occur at any age 1, 7
4. Normal urinalysis does not exclude torsion 1
5. Preserved arterial flow on Doppler does not exclude partial torsion - venous obstruction occurs first 1, 5

Bottom Line Algorithm

Acute testicular pain + swelling + severe pain = TESTICULAR TORSION UNTIL PROVEN OTHERWISE

→ High clinical suspicion (severe pain, abrupt onset, negative Prehn sign, absent cremasteric reflex) → Immediate surgical exploration 1, 2

→ Intermediate suspicion → Urgent Doppler ultrasound BUT proceed to surgery if any delay or if ultrasound equivocal 1

→ Low suspicion (gradual onset, positive Prehn sign, urinalysis suggests infection) → Consider epididymitis, but maintain close follow-up and low threshold for surgical consultation 1, 6