What is the appropriate initial evaluation and management for a male patient in his 50s presenting with scrotal swelling?

Scrotal Swelling in a 50s Male Patient

Immediate Life-Threatening Exclusions

In a male patient in his 50s with scrotal swelling, you must immediately rule out three surgical emergencies: Fournier's gangrene, incarcerated inguinal hernia, and (though rare at this age) testicular torsion. 1

Critical Red Flags Requiring Emergency Surgery

• Fournier's gangrene presents with severe pain, rapidly progressive scrotal swelling, skin necrosis or crepitus, and systemic toxicity (fever, tachycardia, hypotension), requiring urgent surgical debridement and broad-spectrum antibiotics 1
• Incarcerated inguinal hernia requires immediate assessment, particularly if the swelling is reducible or associated with bowel symptoms 1
• Testicular torsion is extremely rare over age 35 but must still be excluded if there is abrupt onset of severe unilateral pain, nausea/vomiting, and negative Prehn sign (pain not relieved by testicular elevation) 2, 1

Most Likely Diagnosis in This Age Group

Epididymitis/epididymo-orchitis is overwhelmingly the most common cause of scrotal pain and swelling in adults, representing approximately 600,000 cases annually in the United States. 2, 1

Key Distinguishing Features of Epididymitis

• Gradual onset of pain over hours to days (versus abrupt onset in torsion) 2, 1
• Subacute progression of swelling 1
• May have urinary symptoms (dysuria, frequency) 1
• Positive Prehn sign (pain relief with testicular elevation) 2

Diagnostic Algorithm

Step 1: Focused Physical Examination

• Inspect for skin changes, erythema, necrosis, or crepitus (Fournier's gangrene) 1
• Assess pain onset (abrupt versus gradual) and severity 2, 1
• Check Prehn sign (elevation relieves pain in epididymitis, not in torsion) 2
• Palpate for inguinal hernia 1

Step 2: Laboratory Testing

• Urinalysis on all patients: pyuria and bacteriuria support epididymitis, though normal urinalysis does not exclude it 3, 1
• Inflammatory markers (WBC, CRP) if infection or Fournier's gangrene suspected 1

Step 3: Imaging - Scrotal Ultrasound with Doppler

Scrotal ultrasound with Doppler is the first-line imaging modality for all patients with scrotal swelling. 3, 1

Essential Ultrasound Components

• Grayscale examination to assess testicular homogeneity, size, and identify masses 2, 3
• Color and Power Doppler to assess testicular perfusion compared to the contralateral testis 2, 3, 1
• Look for specific findings:
  • Epididymitis: enlarged epididymis with increased blood flow on color Doppler, scrotal wall thickening 2, 3
  • Torsion: decreased or absent blood flow, "whirlpool sign" of twisted spermatic cord 2, 3
  • Hydrocele: fluid collection around testis with normal blood flow 4

Management Based on Diagnosis

Epididymitis (Most Common)

Treat with fluoroquinolones (ofloxacin 300 mg orally twice daily for 10 days) or cephalosporins for enteric organisms in men over 35. 1

• Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 1
• Consider tuberculous epididymo-orchitis in patients with risk factors; treat with 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by 4 months of isoniazid and rifampicin 1

If Testicular Torsion Cannot Be Excluded

• Immediate urological consultation is mandatory 3, 1
• Surgical exploration within 6-8 hours of symptom onset to prevent permanent testicular loss 2, 3
• Do not delay surgery for imaging if clinical suspicion is high 3

Other Diagnoses

• Hydrocele: typically managed conservatively unless causing significant discomfort; may require diuretics and leg elevation 4
• Segmental testicular infarction: presents as wedge-shaped avascular area on ultrasound 2, 3
• Acute idiopathic scrotal edema: rare, self-limiting condition with marked scrotal wall thickening but normal testicular vascularity 2, 3

Critical Pitfalls to Avoid

• Normal urinalysis does not exclude testicular torsion or epididymitis 3, 1
• False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion in up to 30% of cases 2, 3
• Significant overlap exists in clinical presentation between different causes of acute scrotal pain, making imaging essential 2, 3
• Never delay surgical exploration for imaging when clinical suspicion for torsion is high, even in older adults 3, 1