What is the appropriate evaluation and management for acute severe testicular pain in an adult male?

Acute Severe Testicular Pain in Adults

Acute severe testicular pain must be treated as testicular torsion—a surgical emergency—until proven otherwise, requiring immediate urological consultation and surgical exploration within 6-8 hours to prevent permanent testicular loss. 1

Immediate Clinical Assessment

When evaluating acute testicular pain, focus on these critical distinguishing features:

Time-Sensitive Red Flags for Torsion

• Abrupt onset of severe, unilateral scrotal pain (versus gradual onset in epididymitis) 1
• Pain accompanied by nausea and vomiting 1, 2
• Negative Prehn sign: pain NOT relieved by elevating the testicle 1, 3
• Absent cremasteric reflex on the affected side (most accurate clinical sign) 4
• Horizontal lie of the testis on examination (correlates with bell-clapper deformity) 5

Age-Specific Considerations

While testicular torsion has a bimodal distribution peaking in neonates and adolescents, it can occur at any age and should never be excluded based on age alone 1. However, in adults over 25 years, epididymitis becomes overwhelmingly more common, representing approximately 600,000 cases annually in the United States 1.

Diagnostic Algorithm

High Clinical Suspicion (Severe acute pain, absent cremasteric reflex, negative Prehn sign)

Proceed directly to surgical exploration without imaging—do not let imaging delay definitive treatment 1, 3. Testicular viability is compromised if not treated within 6-8 hours, with optimal outcomes when surgery occurs within 6 hours 1, 4.

Intermediate Clinical Suspicion

Order urgent Duplex Doppler ultrasound with the following protocol 1:

• Grayscale examination for testicular homogeneity and the "whirlpool sign" (96% sensitivity for twisted spermatic cord) 1
• Color Doppler assessment of testicular perfusion (96-100% sensitivity) 1
• Power Doppler (particularly useful for detecting low-flow states) 1
• Always compare to the contralateral testis as an internal control 1

Critical Ultrasound Findings

For Testicular Torsion:

• Decreased or absent blood flow to the affected testicle 1
• "Whirlpool sign" of twisted spermatic cord (most specific finding) 1
• Enlarged heterogeneous testis appearing hypoechoic 1
• Ipsilateral hydrocele and scrotal skin thickening 1

For Epididymitis (most common in adults):

• Enlarged epididymis with increased blood flow on Doppler 1
• Gradual pain onset with possible abnormal urinalysis 1
• Scrotal wall thickening 1

Critical Pitfalls to Avoid

False-Negative Doppler Results

A normal ultrasound does NOT exclude testicular torsion—false-negative evaluations occur in 30% or more of cases 1, 2. This happens particularly with:

• Partial torsion (<450 degrees) where arterial flow may persist 1
• Spontaneous detorsion 1
• Early presentation within the first few hours 1

When clinical suspicion remains high despite normal Doppler, proceed immediately to surgical exploration 1. The sensitivity of ultrasound ranges from only 69-96.8%, making clinical judgment paramount 1.

Prepubertal Males

Infants and young boys normally have reduced intratesticular blood flow, which can lead to false-positive interpretations 1. Use the contralateral testis for comparison and consider power Doppler for better sensitivity 1.

Definitive Management

Confirmed or Highly Suspected Torsion

• Immediate urological consultation 1, 3
• Urgent surgical exploration with detorsion within 6-8 hours 1
• Bilateral orchiopexy during surgery (the bell-clapper deformity is present in 82% of intermittent torsion cases, putting the contralateral testis at risk) 5
• Manual detorsion can be attempted while awaiting surgery but must be confirmed with restoration of blood flow 4

Confirmed Epididymitis

• Bed rest, scrotal elevation, and analgesics 1
• Antibiotic therapy based on age and risk factors:
  • Sexually active adults <35 years: Ceftriaxone 1000 mg IV/IM plus doxycycline (for STI coverage) 3
  • Older men: Fluoroquinolones or cephalosporins (for enteric organisms) 3

Differential Diagnosis in Adults

Beyond torsion and epididymitis, consider:

• Segmental testicular infarction: Wedge-shaped avascular area on ultrasound, median age 37-38 years 1
• Torsion of testicular appendage: Normal testicular perfusion with localized hyperemia, more common in prepubertal boys but can occur in adults 1, 3
• Acute idiopathic scrotal edema: Rare, self-limiting, marked scrotal wall thickening with minimal pain 1, 3

Key Takeaway for Practice

The 6-8 hour window is absolute—any delay increases the risk of testicular loss 1, 6. When in doubt, consult urology emergently. Missing the diagnosis of testicular torsion, even when patients present early, leads to preventable testicular loss 6. The mantra should be: "Every testicular pain in young adults is testicular torsion until proven otherwise" 6.