What is the appropriate evaluation and management for sudden severe unilateral testicular pain in an adolescent or adult?

Sudden Severe Unilateral Testicular Pain: Emergency Evaluation and Management

Sudden severe unilateral testicular pain in an adolescent or adult must be treated as testicular torsion until proven otherwise, requiring immediate urological consultation and surgical exploration within 6-8 hours to prevent permanent testicular loss. 1

Immediate Clinical Assessment

The critical first step is rapid risk stratification based on clinical presentation:

High-risk features mandating immediate surgical exploration without imaging include: 1

• Abrupt onset of severe scrotal pain (developing within minutes) 1, 2
• Negative Prehn sign (pain NOT relieved with testicular elevation) 1
• Nausea and vomiting 2
• High-riding testicle with abnormal cremasteric reflex 3
• TWIST score ≥6 (indicating >90% probability of torsion) 1

Key distinguishing clinical features by diagnosis: 1

• Testicular torsion: Sudden onset, severe pain, negative Prehn sign, normal urinalysis 1
• Epididymitis: Gradual onset, may have abnormal urinalysis (though normal UA does not exclude it), more common in adults >25 years 1
• Torsion of testicular appendage: Most common in prepubertal boys, may show "blue dot sign" (only 21% of cases) 1

Diagnostic Imaging Protocol

For intermediate clinical suspicion (TWIST score 1-5), obtain urgent Duplex Doppler ultrasound immediately—but never delay surgical exploration if clinical suspicion remains high. 1

Critical Ultrasound Findings

Testicular torsion findings: 1

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

Epididymitis findings: 1

• Enlarged epididymis with INCREASED blood flow on color Doppler 1
• Scrotal wall thickening 1
• Color Doppler shows hyperemia with near 100% sensitivity 1

Critical Imaging Pitfalls

False-negative Doppler evaluations occur in 30% or more of cases, particularly with: 1

• Partial torsion (where arterial flow may persist because venous obstruction occurs first) 1
• Spontaneous detorsion 1, 2
• Early presentation within first few hours 1
• Prepubertal boys with normally reduced intratesticular blood flow 1

When clinical suspicion for torsion remains high despite normal Doppler, proceed immediately to surgical exploration—imaging should never delay definitive treatment. 1

Time-Sensitive Management Algorithm

Immediate Surgical Intervention (Within 6-8 Hours)

Testicular viability is compromised if not treated within 6-8 hours of symptom onset, with surgical outcomes significantly better when surgery occurs within 12 hours. 1

Definitive surgical procedure includes: 1

• Inguinal or scrotal exploration with detorsion of affected testis 1
• Assessment of testicular viability after detorsion 1
• Bilateral orchiopexy to prevent contralateral torsion (82% of patients have Bell-clapper deformity predisposing to bilateral risk) 1

Conservative Management (Only After Torsion Excluded)

For confirmed epididymitis: 1

• Bed rest and scrotal elevation 1
• Analgesics 1
• Appropriate antibiotic therapy based on age and risk factors 1

For torsion of testicular appendage (prepubertal boys): 4

• Usually self-limiting, resolves within 3-10 days 4
• Scrotal support and follow-up within 24-48 hours 4

Age-Stratified Differential Diagnosis

Adolescents and young adults: 1

• Testicular torsion is most common (bimodal distribution with peaks in neonates and postpubertal boys) 1
• Annual incidence: 2.9-3.8 per 100,000 boys under 18 years 1

Adults >25 years: 1

• Epididymitis/epididymo-orchitis is most common (approximately 600,000 cases annually in US) 1
• Testicular torsion is rare in patients >35 years 1

Prepubertal boys: 1

• Torsion of testicular appendage is most common cause 1

Critical Clinical Pitfalls to Avoid

Never rely solely on normal urinalysis to exclude testicular torsion—normal UA does not exclude torsion. 1

Never delay surgical exploration for imaging when clinical suspicion is high—the 6-8 hour window is absolute. 1, 5

Never assume normal Doppler flow excludes torsion—false-negative rate approaches 30% in partial torsion. 1

Always use the contralateral asymptomatic testicle as an internal control during ultrasound evaluation. 1

Significant overlap exists in clinical presentation between different causes of acute scrotal pain—when in doubt, explore surgically. 1, 5