How should a patient presenting with simultaneous testicular and flank pain be evaluated and managed?

Evaluation and Management of Testicular and Flank Pain

A patient presenting with simultaneous testicular and flank pain requires immediate evaluation for testicular torsion as a surgical emergency, while also considering urologic causes that can produce referred pain patterns, particularly ureterolithiasis or upper urinary tract pathology. 1, 2

Immediate Clinical Assessment

Critical Time-Sensitive Evaluation

• Testicular torsion must be excluded first as it requires surgical intervention within 6-8 hours to prevent permanent testicular loss, regardless of the presence of flank pain 1, 2
• Assess the onset and character of testicular pain: abrupt, severe unilateral scrotal pain suggests torsion, while gradual onset suggests epididymitis 1, 2
• Document the temporal relationship between testicular and flank pain onset—simultaneous onset may suggest referred pain from upper urinary tract pathology, while testicular pain preceding flank pain raises concern for torsion with secondary referred pain 1

Key Physical Examination Findings

• Testicular examination: Look for high-riding testicle, absent cremasteric reflex (negative Prehn sign), scrotal swelling, and ecchymosis—these findings strongly suggest torsion 1, 3, 4
• Flank examination: Assess for costovertebral angle tenderness suggesting ureterolithiasis or pyelonephritis 1
• Scrotal transillumination: May be positive with reactive hydrocele in torsion, but severe edema can distort results—do not let this delay intervention 1

Risk Stratification

Age-Based Considerations

• Adolescents and young adults (12-25 years): Testicular torsion has peak incidence in this age group with bimodal distribution (neonates and postpubertal boys) 1, 2
• Adults >25 years: Epididymitis becomes more common, but torsion remains possible and must be excluded 1, 2

TWIST Score Application (for pediatric/adolescent patients 3 months-18 years)

• High TWIST score (≥6): Proceed directly to immediate urological consultation and surgical exploration without imaging 2
• Intermediate TWIST score (1-5): Obtain urgent Duplex Doppler ultrasound 2
• Low TWIST score: Consider alternative diagnoses but maintain high index of suspicion 2

Diagnostic Imaging Protocol

Urgent Scrotal Ultrasound with Duplex Doppler

• Obtain immediately for intermediate clinical suspicion, but do not delay surgical exploration if high clinical suspicion exists 1, 2
• Key findings for testicular torsion: Decreased or absent blood flow to affected testicle (sensitivity 69-96.8%, specificity 87-100%), "whirlpool sign" of twisted spermatic cord (96% sensitivity, 99% specificity), enlarged heterogeneous hypoechoic testis, ipsilateral hydrocele, and scrotal wall thickening 1, 2
• Power Doppler is superior for detecting low-flow states, particularly in prepubertal boys with normally reduced intratesticular blood flow 1
• Use contralateral testicle as internal control for comparative flow assessment 1

Critical Diagnostic Pitfalls

• False-negative Doppler occurs in 30% of cases, particularly with partial torsion (<450 degrees), spontaneous detorsion, or early presentation 1
• Partial torsion may show persistent arterial flow because venous obstruction occurs first due to lower pressure, creating diagnostic confusion 1
• Normal ultrasound does not exclude torsion—when clinical suspicion remains high, proceed to surgical exploration 1, 2

Concurrent Evaluation for Flank Pain Etiology

• Urinalysis: Check for hematuria (suggests ureterolithiasis), pyuria (suggests infection), but normal urinalysis does not exclude testicular torsion 1
• Renal ultrasound or CT urography may be indicated after testicular pathology is addressed, but should not delay management of suspected torsion 1

Management Algorithm

If Testicular Torsion Confirmed or Highly Suspected

• Immediate urological consultation and prompt surgical exploration is the definitive treatment and should not be delayed 1, 2, 4
• Surgical detorsion must occur within 6-8 hours of symptom onset to prevent permanent ischemic damage 1, 2
• Bilateral orchiopexy is mandatory during surgery, as 82% of patients have Bell clapper deformity predisposing to contralateral torsion 1
• Manual detorsion may be attempted while awaiting surgery, but ultrasound guidance improves success rates 3

If Epididymitis/Epididymo-orchitis Diagnosed

• Ultrasound findings: Enlarged epididymis with increased blood flow on color Doppler, scrotal wall thickening, preserved or increased testicular perfusion 1, 2
• Treatment: Appropriate antibiotics based on age and risk factors, bed rest, scrotal elevation, and analgesics 1, 2
• Up to 20% concomitant orchitis rate may occur 1

If Ureterolithiasis Suspected as Cause of Combined Pain

• Testicular pain from ureterolithiasis represents referred pain via shared innervation (genitofemoral nerve, ilioinguinal nerve) 1
• Once testicular torsion is excluded, manage according to stone size, location, and degree of obstruction 1

Common Clinical Scenarios and Pitfalls

Scenario 1: Intermittent Testicular Torsion with Flank Pain

• Spontaneous torsion and detorsion can occur, creating confusing intermittent symptoms that may be misattributed to renal colic 5
• Wave-like pain pattern with sensitivity to touch and movement should raise suspicion for intermittent torsion 1
• Even with normal Doppler, if clinical suspicion persists, proceed to surgical exploration 1, 2

Scenario 2: Markedly Enlarged Scrotum with Bluish Hue

• This signifies vascular compromise and possible hemorrhagic necrosis, indicating advanced torsion requiring immediate surgical intervention 1
• Do not delay for imaging in this scenario 1, 2

Scenario 3: Concomitant Urethral Injury Concerns

• Evaluate for urethral injury if blood at meatus, gross hematuria, or inability to void are present, particularly with bilateral corporal fracture or penetrating trauma 6
• Options include urethroscopy or retrograde urethrogram 6

Key Takeaway for Combined Testicular and Flank Pain

The presence of flank pain does not reduce the urgency of excluding testicular torsion. Treat any acute testicular pain as a potential surgical emergency until torsion is definitively excluded, as testicular viability is compromised within 6-8 hours. 1, 2 The flank pain component can be addressed after testicular pathology is managed or ruled out. When in doubt, immediate urological consultation is mandatory. 1, 2, 4