Acute Right Testicular Pain: Evaluation and Management
Immediate Priority: Rule Out Testicular Torsion
Acute testicular pain must be treated as testicular torsion until proven otherwise, requiring immediate evaluation and urological consultation if clinical suspicion is high, as testicular viability is compromised if surgical intervention does not occur within 6-8 hours of symptom onset. 1
Clinical Assessment Algorithm
Key Historical Features to Obtain
- Onset and duration of pain: Abrupt, severe onset strongly suggests torsion, while gradual onset suggests epididymitis 1, 2
- Time from symptom onset: Critical for determining salvage potential—surgical outcomes are significantly better when intervention occurs within 6-8 hours 1
- Associated symptoms: Nausea and vomiting are characteristic of testicular torsion 3
- Age of patient: Torsion has a bimodal distribution with peaks in neonates and postpubertal boys, while epididymitis is more common in adults over 25 years 1
Critical Physical Examination Findings
For Testicular Torsion (Surgical Emergency):
- Absent cremasteric reflex: Highly predictive of torsion 2, 3
- Negative Prehn sign: Pain is NOT relieved when the testicle is elevated 1
- Testicular retraction: High-riding testicle position 2, 3
- Scrotal swelling and hyperemia: Present in >90% of cases 2
- Markedly enlarged scrotum with bluish hue: Indicates vascular compromise and possible hemorrhagic necrosis 1
For Epididymitis (Most Common in Adults):
- Positive Prehn sign: Pain relieved with testicular elevation 1
- Gradual onset of pain and tenderness 1
- May have urethral discharge or dysuria 1
Diagnostic Imaging Protocol
When to Order Imaging vs. Immediate Surgery
High clinical suspicion for torsion (absent cremasteric reflex, sudden onset, high-riding testis): Proceed directly to surgical exploration without delay for imaging 1, 2
Intermediate clinical suspicion: Obtain urgent Duplex Doppler ultrasound 1
Ultrasound Examination Components
Grayscale findings for torsion:
- Enlarged heterogeneous testis appearing hypoechoic 1
- "Whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
- Ipsilateral hydrocele and scrotal wall thickening 1
Color/Power Doppler findings for torsion:
- Decreased or absent testicular blood flow compared to contralateral side 1
- Sensitivity ranges from 69-96.8%, specificity 87-100% 1, 4
- Power Doppler is more sensitive for low-flow states, particularly useful in prepubertal boys 1
Spectral Doppler analysis:
- Diminished arterial velocity, decreased or absent diastolic flow 1
- Increased resistive index or reversed diastolic flow 1
Ultrasound findings for epididymitis:
- Enlarged epididymis with increased blood flow on color Doppler 1
- Scrotal wall thickening and hydrocele 1
Critical Diagnostic Pitfalls
False-Negative Ultrasound Results
Ultrasound can miss torsion in up to 30% of cases, particularly with:
- Partial or incomplete torsion where arterial flow may persist because venous obstruction occurs first 1
- Spontaneous detorsion 1
- Early presentation within the first few hours when the testis may appear normal 1
Clinical judgment supersedes imaging: When clinical suspicion remains high despite normal Doppler, proceed immediately to surgical exploration 1, 2
False-Positive Ultrasound Results
- Prepubertal boys normally have reduced intratesticular blood flow, which can mimic torsion 1
- Always use the contralateral asymptomatic testicle as an internal control 1
Management Based on Diagnosis
Testicular Torsion (Confirmed or Highly Suspected)
Immediate urological consultation and surgical exploration within 6-8 hours 1, 2
Surgical procedure includes:
- Detorsion of the 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
- Orchiectomy if testis is nonviable 2
Salvage rates:
Epididymitis/Epididymo-orchitis
Conservative management:
- Bed rest and scrotal elevation 1
- Analgesics for pain control 1
- Antibiotics based on age and risk factors 1
Diagnostic support:
- Urinalysis may show pyuria/bacteriuria, though normal urinalysis does not exclude epididymitis 1
- C-reactive protein >24 mg/L suggests epididymitis over torsion 3
Torsion of Testicular Appendage
- Most common cause of testicular pain in prepubertal boys 1
- "Blue dot sign" is pathognomonic but only seen in 21% of cases 1
- Usually self-limiting, resolves in 3-10 days 5
- Outpatient management with scrotal support and follow-up in 24-48 hours 5
Age-Stratified Differential Considerations
Neonates and prepubertal boys:
Adolescents and postpubertal boys:
Adults:
- Epididymitis/epididymo-orchitis (overwhelmingly most common—600,000 cases annually in US) 1
- Testicular torsion rare over age 35 1
Point-of-Care Handheld Doppler
Emergency physicians can use handheld Doppler as a first-line triaging tool with 97.8% specificity for ruling out testicular torsion 4. However, this should not replace formal ultrasound when available, and high clinical suspicion should always prompt immediate surgical consultation regardless of Doppler findings 1.