What is the appropriate workup and initial management for a 46-year-old male with a two-month history of intermittent testicular pain associated with sexual activity?

Testicular Pain During Sexual Activity: Workup and Management

Initial Assessment and Most Likely Diagnosis

In a 46-year-old male with two months of testicular pain during sexual activity and excessive testicular mobility, the most likely diagnosis is chronic intermittent testicular torsion or "bell-clapper deformity," which requires urgent urological evaluation and likely bilateral orchiopexy to prevent complete torsion and testicular loss. 1

The bell-clapper deformity is found in 82% of patients with intermittent testicular torsion and presents with recurrent episodes of testicular pain that may spontaneously resolve. 2 While testicular torsion is rare in patients over 35 years of age, intermittent torsion can occur at any age and the described excessive testicular movement during thrusting strongly suggests inadequate fixation of the testis within the scrotum. 1

Critical Immediate Considerations

Rule Out Complete Torsion First

• Any acute scrotal pain must be treated as a potential surgical emergency until torsion is excluded. 1
• Although symptoms have been present for 2 months (suggesting intermittent rather than complete torsion), the patient requires urgent evaluation because:
  • Intermittent torsion can progress to complete torsion at any time 1
  • Testicular viability is compromised if complete torsion is not treated within 6-8 hours 1
  • False-negative Doppler ultrasound occurs in 30% or more of cases, particularly with partial torsion or spontaneous detorsion 2

Key Distinguishing Features from Other Causes

• Epididymitis is the most common cause of testicular pain in adults over 25 years, but typically presents with gradual onset of pain, not specifically related to sexual activity. 1
• The patient's description of pain specifically during thrusting with visible excessive testicular movement is highly suggestive of mechanical/anatomical pathology rather than infection 1
• Testicular torsion characteristically presents with abrupt onset of severe scrotal pain, while epididymitis has more gradual pain onset 1

Diagnostic Workup Algorithm

Step 1: Urgent Physical Examination

Perform focused examination looking for:

• Testicular position, size, and consistency compared to contralateral side 1
• Prehn sign: In testicular torsion, pain is NOT relieved when the testicle is elevated (negative Prehn sign) 1
• Cremasteric reflex: Often absent in torsion 1
• Palpable masses or asymmetry that could suggest malignancy 2
• Signs of epididymitis: enlarged, tender epididymis 1

Step 2: Immediate Duplex Doppler Ultrasound

Order urgent Duplex Doppler ultrasound of the scrotum as the first-line imaging study, with sensitivity of 69-96.8% and specificity of 87-100% for diagnosing testicular torsion. 1

The ultrasound protocol must include:

• Grayscale examination to assess testicular homogeneity and identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
• Color Doppler assessment of testicular perfusion compared to the contralateral side (96-100% sensitivity) 1
• Power Doppler for increased sensitivity to low-flow states 1
• Spectral Doppler analysis of upper, mid, and lower poles of each testicle to detect regional flow variations 1
• Use the contralateral asymptomatic testicle as an internal control 1

Step 3: Laboratory Studies

• Urinalysis to evaluate for urinary tract infection or urethritis 1
• If malignancy is suspected (any palpable mass or persistent abnormality), obtain serum tumor markers immediately (AFP, β-hCG, LDH) 2

Critical Diagnostic Pitfalls

Understanding Ultrasound Limitations

• Partial or incomplete torsion presents the greatest diagnostic challenge, as arterial flow may persist because venous obstruction occurs first. 1
• Complete torsion >450 degrees results in absent arterial and venous flow, but partial torsion can show diminished arterial velocity and decreased diastolic flow. 1
• When clinical suspicion for testicular torsion remains high despite normal imaging, immediate urological consultation and surgical exploration should proceed without delay. 2

Do Not Miss These Findings

• The "whirlpool sign" on grayscale imaging is the most specific ultrasound sign for testicular torsion. 1
• Ultrasound findings for epididymitis include enlarged epididymis with increased blood flow on color Doppler, which would argue against torsion. 1, 3
• Segmental testicular infarction presents as a wedge-shaped avascular area on ultrasound and can mimic other pathology. 1

Management Based on Findings

If Intermittent Torsion is Confirmed or Highly Suspected

Immediate urological consultation for bilateral orchiopexy is mandatory, even if current ultrasound shows normal flow. 2

Rationale:

• The presence of bell-clapper deformity mandates bilateral orchiopexy during surgery to prevent contralateral torsion. 2
• Surgical exploration should involve inguinal or scrotal exploration with assessment of testicular viability and bilateral orchiopexy to prevent recurrence. 2
• The chronic nature of symptoms (2 months) suggests this is intermittent torsion with spontaneous detorsion, but definitive surgical fixation is required to prevent complete torsion 1

If Epididymitis is Diagnosed

• Management includes bed rest, scrotal elevation, analgesics, and appropriate antibiotic therapy according to age and risk factors. 1
• If symptoms fail to improve within 3 days of appropriate antimicrobial therapy, urgent urological consultation is indicated. 2

If Ultrasound is Normal but Clinical Suspicion Remains High

Do not be falsely reassured by normal imaging. The following steps are critical:

• Review the original ultrasound images with a radiologist to ensure adequate technique and complete evaluation. 2
• Consider repeat Duplex Doppler ultrasound with specific attention to power Doppler assessment and spectral Doppler analysis. 2
• Proceed with urological consultation regardless, as false-negative evaluations occur in 30% or more of cases. 1

Additional Differential Considerations (Less Likely Given History)

Testicular Malignancy

• Germ cell tumors can present with pain in up to 30% of cases, and patients more commonly present with testicular discomfort or swelling suggestive of epididymitis. 2
• Any palpable testicular mass or persistent abnormality after evaluation warrants serum tumor markers and urological referral. 2

Chronic Epididymitis

• Epididymitis represents approximately 600,000 cases annually in the United States and is the most common cause of testicular pain in adults. 1
• However, the specific association with sexual activity and visible excessive testicular movement makes this less likely than intermittent torsion 1

Bottom Line Recommendation

This 46-year-old male requires urgent urological consultation within 24-48 hours, not emergent surgery (unless acute complete torsion develops), because the chronic intermittent nature suggests bell-clapper deformity with recurrent partial torsion. 1, 2 The definitive treatment is bilateral orchiopexy to prevent future complete torsion and potential testicular loss. Do not delay referral waiting for imaging—if ultrasound cannot be obtained immediately, refer to urology first. 1