What is the appropriate diagnosis and treatment for a male in his late 50s presenting with painful testes?

Acute Testicular Pain in a Male in His Late 50s

In a male in his late 50s with painful testes, epididymitis/epididymo-orchitis is overwhelmingly the most likely diagnosis, but testicular torsion must be urgently excluded despite being rare in this age group, as delayed diagnosis can result in testicular loss within 6-8 hours.

Age-Specific Diagnostic Considerations

Epididymitis is the primary diagnosis to consider in this age group, representing approximately 600,000 cases annually in the United States and being the most common cause of testicular pain in adults 1. However, testicular torsion, while rare in patients over 35 years of age, remains a surgical emergency that cannot be missed 1.

Immediate Clinical Assessment

Key Historical Features to Elicit

• Onset of pain: Testicular torsion presents with abrupt onset of severe scrotal pain developing within minutes, while epididymitis has a gradual onset 1, 2
• Associated symptoms: Nausea and vomiting strongly suggest torsion 2
• Pain pattern: Determine if pain is constant or wave-like 1

Critical Physical Examination Findings

• Prehn sign: Pain NOT relieved by elevating the testis (negative Prehn sign) suggests testicular torsion, while pain relief suggests epididymitis 1, 3
• Cremasteric reflex: Absent in torsion 4
• Testicular position: High-riding testicle suggests torsion 4

Diagnostic Algorithm

Step 1: Risk Stratification

If high clinical suspicion for torsion exists (sudden onset, severe pain, negative Prehn sign, absent cremasteric reflex), proceed directly to surgical exploration without imaging 1, 3. Do not delay surgery for diagnostic studies when clinical suspicion is high 4.

Step 2: Imaging for Intermediate Suspicion

For intermediate clinical suspicion, obtain urgent Duplex Doppler ultrasound of the scrotum 1, 3. This should include:

• Grayscale examination: Look for the "whirlpool sign" of twisted spermatic cord (96% sensitivity), enlarged heterogeneous testis, ipsilateral hydrocele, and scrotal skin thickening 1
• Color Doppler assessment: Compare testicular perfusion to the contralateral side as an internal control 1
• Power Doppler: More sensitive for detecting low-flow states 1

Step 3: Interpretation of Ultrasound Findings

Findings suggesting testicular torsion:

• Decreased or absent blood flow to the affected testicle 1, 2
• Whirlpool sign of twisted spermatic cord 1
• Enlarged heterogeneous testis appearing hypoechoic 1

Findings suggesting epididymitis:

• Enlarged epididymis with increased blood flow on color Doppler 1
• Scrotal wall thickening and hydrocele 1
• Normal or increased testicular perfusion 1

Critical Diagnostic Pitfalls

Color Doppler ultrasound has significant limitations, with sensitivity ranging from 69% to 96.8% and false-negative evaluations occurring in 30% or more of cases, particularly with partial torsion or spontaneous detorsion 1. When clinical suspicion for torsion remains high despite normal Doppler findings, immediate urological consultation and surgical exploration should proceed 1.

Management Based on Diagnosis

If Testicular Torsion is Confirmed or Highly Suspected

Immediate urological consultation and urgent surgical exploration within 6-8 hours of symptom onset 1, 2, 3. Testicular viability is compromised if not treated within this critical window, with surgical outcomes significantly better when surgery occurs within 12 hours 1. The procedure should include bilateral orchiopexy to prevent contralateral torsion 1.

If Epididymitis is Diagnosed

Treatment includes:

• Bed rest, scrotal elevation, and analgesics 1
• Antibiotic selection based on age and risk factors 3:
  • For sexually transmitted infections: Ceftriaxone 1000 mg IV/IM plus doxycycline 3
  • For enteric organisms (more common in older men): Fluoroquinolones or cephalosporins 3

Alternative Diagnoses to Consider

• Segmental testicular infarction: Presents with a wedge-shaped avascular area on ultrasound, median age 37-38 years 1
• Acute idiopathic scrotal edema: Rare, self-limiting condition with marked scrotal wall thickening but minimal pain, diagnosis of exclusion 1, 3

Key Clinical Principle

There is significant overlap in clinical presentation between different causes of acute scrotal pain 1. Therefore, any acute scrotal pain must be treated as a potential surgical emergency until torsion is excluded 1, 3. The consequences of missing testicular torsion (testicular loss, infertility) far outweigh the risks of unnecessary surgical exploration.