What is the management of acute painful testicular swelling in an adult or adolescent?

Management of Acute Painful Testicular Swelling

Testicular torsion must be excluded first in any patient presenting with acute painful testicular swelling, as this is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss. 1, 2

Immediate Risk Stratification

High-Risk Features Requiring Emergent Urological Consultation

• Sudden, severe onset of pain (not gradual) 1, 2
• Adolescent or young adult male (bimodal distribution: neonates and postpubertal boys) 1, 2
• Negative Prehn sign (pain NOT relieved with testicular elevation) 1
• Absence of urinary symptoms or urethral discharge 2
• Markedly enlarged scrotum with bluish hue (indicates vascular compromise) 1

If high clinical suspicion exists, proceed directly to emergency urological consultation without waiting for imaging, as testicular viability is lost within 6-8 hours. 1, 2

Intermediate-Risk Patients: Urgent Doppler Ultrasound

For patients with intermediate clinical suspicion (TWIST score 1-5), obtain urgent Duplex Doppler ultrasound within hours, not days 1:

Key ultrasound findings for testicular torsion:

• Decreased or absent blood flow to affected testicle (sensitivity 69-96.8%, specificity 87-100%) 1
• "Whirlpool sign" of twisted spermatic cord (96% sensitivity, most specific finding) 1
• Enlarged heterogeneous testis appearing hypoechoic 1
• Ipsilateral hydrocele and scrotal wall thickening 1

Critical pitfall: False-negative Doppler occurs in 30% of cases, particularly with partial torsion or spontaneous detorsion. Normal Doppler does NOT exclude torsion if clinical suspicion remains high—proceed to surgical exploration. 1

Definitive Management by Diagnosis

Testicular Torsion (Surgical Emergency)

Immediate urological consultation and surgical exploration with detorsion within 6-8 hours of symptom onset. 1, 2

• Salvage rates exceed 90% when surgery occurs within 6 hours 3
• Surgical procedure includes bilateral orchiopexy to prevent contralateral torsion (82% have Bell-clapper deformity) 1
• Post-operative care: bed rest, scrotal elevation, analgesics 1

Epididymitis/Epididymo-orchitis (Most Common in Adults)

If torsion is excluded, epididymitis is the most likely diagnosis in adults with testicular redness, warmth, and swelling. 2

Clinical features distinguishing epididymitis from torsion:

• Gradual onset of pain over hours to days 2
• Palpable swelling of epididymis 2
• Ultrasound shows enlarged epididymis with increased blood flow on Doppler (opposite of torsion) 1, 2
• May have abnormal urinalysis (though normal urinalysis does NOT exclude epididymitis) 1

Diagnostic workup before treatment:

• Gram-stained urethral smear or intraurethral swab (>5 PMNs per oil immersion field indicates urethritis) 2
• NAAT for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 2

Empiric antibiotic therapy (start immediately before culture results):

For sexually active men <35 years (likely STI-related): 2

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

Supportive measures: 1, 2

• Bed rest, scrotal elevation, analgesics until inflammation subsides

Follow-up: Re-evaluate within 3 days if no improvement. If swelling persists after completing antibiotics, comprehensive evaluation needed to exclude tumor, abscess, testicular cancer, tuberculosis, or fungal epididymitis. 2

Sexual partner management: Refer partners for evaluation if contact occurred within 60 days; avoid sexual intercourse until both complete therapy. 2

Torsion of Testicular Appendage (Most Common in Prepubertal Boys)

• Ultrasound shows normal testicular perfusion with localized hyperemia near appendage 1
• "Blue dot sign" is pathognomonic but only seen in 21% of cases 1
• Generally does not require surgical intervention 4
• Conservative management with analgesics and observation 1

Other Differential Diagnoses to Consider

Testicular tumor: 5

• Painless solid testicular mass is pathognomonic 5
• Critical pitfall: Hydrocele can mask underlying testicular tumor—ultrasound is essential to visualize the testis itself 6
• Any persistent testicular abnormality after trial of antibiotics warrants ultrasound and tumor marker evaluation (β-HCG, AFP, LDH) 5

Segmental testicular infarction: 1

• Classic wedge-shaped avascular area on ultrasound 1
• May present as round lesions with variable Doppler flow 1

Acute idiopathic scrotal edema: 1

• Rare, self-limiting condition with marked scrotal wall thickening 1
• Usually painless or minimally painful 1
• Diagnosis of exclusion 1

Critical Clinical Pitfalls

• Never assume epididymitis without excluding torsion first, especially in adolescents and young adults—there is significant overlap in clinical presentation. 2
• Normal urinalysis does NOT exclude testicular torsion. 1, 2
• Power Doppler is more sensitive than color Doppler for detecting low-flow states, particularly in prepubertal boys. 1
• Always use the contralateral asymptomatic testicle as an internal control during ultrasound evaluation. 1
• Reactive hydrocele can be present in torsion, potentially causing positive transillumination despite the underlying emergency—do not let this delay surgical intervention. 1