What is the appropriate evaluation and management for acute right testicular pain with swelling?

Acute Right Testicular Pain with Swelling: Evaluation and Management

Immediate Priority: Rule Out Testicular Torsion

Testicular torsion must be excluded first as this is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular loss. 1, 2

Critical Time-Sensitive Actions

• Obtain immediate urological consultation if clinical suspicion is high, as testicular viability is compromised without prompt surgical detorsion within 6-8 hours of symptom onset 1, 2
• Do not delay surgical exploration for imaging when clinical suspicion is high—time to surgery is the most critical factor in testicular salvage 3, 4

Clinical Assessment Algorithm

Key Historical Features to Distinguish Torsion from Epididymitis

Testicular Torsion:

• Abrupt onset of severe, unilateral scrotal pain 1, 2
• Pain not relieved by testicular elevation (negative Prehn sign) 1
• More common in adolescents and young adults (bimodal distribution: neonates and postpubertal boys aged 12-18 years) 1, 2

Epididymitis:

• Gradual onset of pain over hours to days 1, 2
• More common in adults over 25 years of age 2
• May have dysuria, urethral discharge, or fever 5

Physical Examination Findings

• Torsion indicators: Absent cremasteric reflex, high-riding testicle, horizontal testicular lie, markedly enlarged scrotum with bluish hue (indicating vascular compromise) 1
• Epididymitis indicators: Tender, enlarged epididymis, possible scrotal wall erythema, preserved cremasteric reflex 5, 2

Diagnostic Workup

Laboratory Testing

• Urinalysis with microscopy (normal urinalysis does NOT exclude torsion) 1
• Gram stain of urethral discharge if present (>5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 5
• Nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis if epididymitis suspected 5

Imaging Protocol

Duplex Doppler ultrasound is the first-line imaging study with sensitivity of 69-96.8% and specificity of 87-100% for testicular torsion 1, 2

Key ultrasound findings for torsion:

• Decreased or absent testicular blood flow compared to contralateral side 1, 2
• "Whirlpool sign" of twisted spermatic cord (96% sensitivity, 99% specificity) 2
• Enlarged heterogeneous testis appearing hypoechoic 1
• Ipsilateral hydrocele and scrotal wall thickening 1

Key ultrasound findings for epididymitis:

• Enlarged epididymis with increased blood flow on color Doppler 1, 2
• Scrotal wall thickening and possible hydrocele 1
• Normal or increased testicular perfusion 2

Critical Imaging Pitfalls

• False-negative Doppler occurs in up to 30% of cases, particularly with partial torsion (<450 degrees), spontaneous detorsion, or early presentation 1
• Partial torsion may show diminished arterial velocity and decreased diastolic flow rather than complete absence of flow 1
• Power Doppler is more sensitive for detecting low-flow states, especially in prepubertal boys 1, 2
• Never delay surgical exploration based on imaging alone when clinical suspicion remains high 1, 2

Management Based on Diagnosis

Confirmed or Highly Suspected Testicular Torsion

• Immediate urological consultation and emergency surgical exploration without delay 1, 2
• Surgical detorsion with bilateral orchiopexy (to prevent contralateral torsion due to bell-clapper deformity present in 82% of cases) 1
• Testicular salvage rates decline dramatically after 6-8 hours: intervention within this window is essential 1, 2, 4

Epididymitis Management

For sexually active men <35 years (likely C. trachomatis or N. gonorrhoeae):

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 5

For men >35 years or enteric organism suspected:

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 5

Adjunctive measures:

• Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 5, 2
• Reevaluate if no improvement within 3 days—consider alternative diagnoses including abscess, tumor, or testicular cancer 5

Sex Partner Management for Epididymitis

• Evaluate and treat sex partners if contact occurred within 60 days preceding symptom onset 5
• Instruct patient to avoid sexual intercourse until both patient and partners complete therapy and are asymptomatic 5

Additional Differential Diagnoses to Consider

• Torsion of testicular appendage: Most common in prepubertal boys, "blue dot sign" (only visible in 21% of cases), normal testicular perfusion with localized hyperemia, managed conservatively with NSAIDs 1, 2
• Segmental testicular infarction: Wedge-shaped avascular area on ultrasound, median age 37-38 years 1
• Testicular tumor: Any persistent testicular mass or swelling after antibiotic treatment warrants ultrasound and tumor marker evaluation (AFP, β-HCG, LDH) 5
• Fournier's gangrene: Rapidly progressive necrotizing fasciitis requiring emergent surgical debridement—suspect if severe pain, systemic toxicity, crepitus, or skin necrosis present 3, 6

Common Clinical Pitfalls

• Treating presumed epididymitis with antibiotics without excluding torsion first—always maintain high suspicion for torsion until definitively ruled out 1, 2
• Relying solely on normal Doppler ultrasound to exclude torsion when clinical suspicion remains high 1
• Delaying surgical consultation for additional testing when torsion is likely 2
• Assuming normal urinalysis excludes torsion—it does not 1
• Missing testicular cancer by attributing persistent swelling to resolved infection without follow-up imaging 5