How should I evaluate and manage a 35-year-old man with testicular pain and hemospermia who has a normal scrotal ultrasound?

Evaluation and Management of Testicular Pain with Hemospermia and Normal Ultrasound in a 35-Year-Old

In a 35-year-old man with testicular pain and hemospermia but normal scrotal ultrasound, the most likely diagnosis is epididymitis or prostatitis, and you should proceed with urinalysis, urine culture, blood pressure measurement, and consider transrectal ultrasound of the prostate and seminal vesicles to identify the underlying inflammatory or infectious cause. 1, 2

Understanding the Clinical Context

At 35 years of age, this patient falls into a critical diagnostic zone where:

• Testicular torsion is extremely rare in patients over 35 years, making it a less likely consideration despite the testicular pain 1
• Epididymitis/epididymo-orchitis is overwhelmingly the most common cause of testicular pain in adults, representing approximately 600,000 cases annually in the United States 1
• Hemospermia in men under 40 years is typically benign and self-limiting, with infections or inflammatory disorders accounting for 39-55% of cases 2, 3

Key Diagnostic Considerations

The Normal Ultrasound Finding

The normal scrotal ultrasound is reassuring but does not complete the evaluation because:

• Color Doppler has variable sensitivity (69-96.8%) and false-negative evaluations can occur in up to 30% of cases, particularly with partial torsion or early presentation 1
• However, given the patient's age and the presence of hemospermia (which is not typical for torsion), epididymitis remains the primary differential 1, 4

Hemospermia as a Diagnostic Clue

The presence of hemospermia significantly narrows the differential diagnosis:

• Urogenital infections are the second most common cause of hemospermia after iatrogenic trauma 4
• Inflammatory and infectious pathologies account for 39-55% of hemospermia cases 3
• Prostatitis and epididymitis are predisposing conditions for hemospermia 3
• In 30-70% of cases, there is no association with significant pathology, but persistent symptoms warrant investigation 3

Algorithmic Approach to Evaluation

Immediate Assessment (Already Completed)

• ✓ Scrotal ultrasound with Doppler - normal findings make complete testicular torsion unlikely 1

Next Steps in Evaluation

1. Basic Laboratory Studies:

• Urinalysis and urine culture to identify urinary tract infection or urethritis 1, 4
• Blood pressure measurement to exclude hypertension as a systemic cause of hemospermia 3, 4
• PSA testing if age-appropriate and recurrent symptoms 3, 5

2. Physical Examination Details:

• Digital rectal examination to assess prostate for tenderness, enlargement, or masses 4, 6
• Genital examination for urethral discharge, testicular masses, or epididymal tenderness 4, 5
• Abdominal palpation to identify hepatosplenomegaly or renal enlargement 5

3. Advanced Imaging (If Initial Workup Unrevealing):

• Transrectal ultrasound (TRUS) is the most useful next step for persistent or recurrent hemospermia, as it can identify prostatic calculi, cysts, prostatic varices, inflammatory changes, and seminal vesicle pathology 3, 5
• MRI may serve as a problem-solving tool when ultrasound findings are equivocal or to rule out rare causes 7, 6

Management Based on Findings

If Epididymitis/Epididymo-orchitis is Confirmed:

Clinical features supporting this diagnosis:

• Gradual onset of pain (versus abrupt onset in torsion) 1
• May have abnormal urinalysis, though normal urinalysis does not exclude epididymitis 1
• Enlarged epididymis with increased blood flow on Doppler (though your ultrasound was reported as normal, subtle changes may have been missed) 1

Treatment approach:

• Bed rest, scrotal elevation, and analgesics until inflammation subsides 1
• Appropriate antibiotic therapy based on age and risk factors (typically fluoroquinolones or doxycycline for sexually transmitted pathogens in younger men, or fluoroquinolones alone for enteric organisms in older men) 1

If Prostatitis is Identified:

• Appropriate antimicrobial therapy based on culture results 6
• Anti-inflammatory medications for symptom relief 2

Critical Clinical Pitfalls to Avoid

1. Don't Dismiss Persistent or Recurrent Symptoms:

• In patients 40 years or older, or those with persistent/recurrent conditions, it is necessary to exclude urogenital malignant disorders 6, 5
• While your patient is 35, recurrent or persistent hemospermia warrants thorough investigation including TRUS, cystoscopy, and potentially MRI 3, 4

2. Don't Assume Normal Ultrasound Excludes All Pathology:

• Segmental testicular infarction can present with variable Doppler flow and may not always be obvious 1
• Early or intermittent testicular torsion can have normal Doppler findings 1
• However, when clinical suspicion for torsion remains high despite normal Doppler, immediate urological consultation should proceed 1

3. Don't Overlook Systemic Causes:

• Arterial hypertension and hematologic disorders are predisposing conditions for hemospermia 3, 4
• Blood pressure measurement is mandatory in the initial evaluation 4, 6

When to Involve Urology

Immediate urological consultation if:

• Clinical suspicion for torsion remains high despite reassuring ultrasound (though less likely given age and hemospermia) 1
• Persistent or recurrent symptoms despite appropriate treatment 4, 5
• Abnormal findings on TRUS requiring biopsy or intervention 5
• Hematuria accompanying hemospermia, which may indicate bladder or upper tract pathology 2

Reassurance and Follow-up

For a single episode with benign findings:

• Simple reassurance is often sufficient in younger patients with one episode 3, 5
• Close monitoring with investigation only if symptoms recur is appropriate 5
• Most cases are benign and self-limiting, resolving in several weeks 6

However, given the combination of testicular pain AND hemospermia:

• This patient warrants more than simple reassurance
• Proceed with urinalysis, blood pressure, and consider TRUS to identify the underlying inflammatory or infectious cause 3, 4, 5