How should a male adolescent or adult with painful scrotal swelling be evaluated and managed?

Evaluation and Management of Painful Scrotal Swelling in Male Adolescents and Adults

Testicular torsion must be immediately excluded in any male with painful scrotal swelling, as surgical intervention within 6-8 hours is critical to prevent permanent testicular loss. 1, 2

Immediate Assessment: Rule Out Surgical Emergency

The first priority is determining whether testicular torsion is present, as this is a time-sensitive surgical emergency. Key clinical features that distinguish torsion include:

• Sudden onset of severe pain developing within minutes, often with nausea and vomiting 1, 2, 3
• Absent cremasteric reflex - this finding is strongly associated with testicular torsion and is one of the most reliable clinical signs 1, 3
• Negative Prehn sign - pain is NOT relieved when the testicle is elevated 1, 2
• High-riding or retracted testicle - testicular retraction is highly predictive of torsion 1, 3
• Normal urinalysis - absence of urethritis or urinary tract infection on initial testing suggests torsion rather than infection 1, 2

Critical Action Point

If clinical suspicion for torsion is high, proceed immediately to urological consultation and surgical exploration WITHOUT waiting for imaging or administering analgesia, as pain relief may mask worsening ischemia. 1, 2 Testicular viability is compromised if surgery is delayed beyond 6-8 hours from symptom onset. 1, 2

Diagnostic Algorithm Based on Clinical Suspicion

High Suspicion for Torsion (TWIST Score or Clinical Features)

• Immediate urological consultation for surgical exploration 1, 2
• Do NOT delay for imaging 1, 2
• Surgical detorsion and bilateral orchiopexy within 6-8 hours 1

Intermediate Suspicion

• Urgent Duplex Doppler ultrasound is the first-line imaging study 1, 2
• Grayscale examination should identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) and assess for enlarged heterogeneous testis 1
• Color/Power Doppler assessment evaluates testicular perfusion with 96-100% sensitivity, though false-negatives occur in 30% of cases with partial torsion 1
• Use the contralateral testicle as an internal control for flow comparison 1
• If ultrasound shows decreased or absent blood flow, proceed immediately to surgery 1, 2

Low Suspicion with Infectious Symptoms

• Proceed with evaluation for epididymitis (see below) 2

Evaluation for Epididymitis (Most Common Cause in Adults)

Epididymitis presents with gradual onset of pain and is the most common cause of testicular pain in adults, representing approximately 600,000 cases annually in the United States. 1 The diagnostic workup includes:

• Gram-stained smear of urethral exudate or intraurethral swab for urethritis (>5 polymorphonuclear leukocytes per oil immersion field) 4
• Culture or nucleic acid amplification test of intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 4
• First-void uncentrifuged urine examination for leukocytes if urethral Gram stain is negative 4
• Syphilis serology and HIV testing 4
• Ultrasound findings include enlarged epididymis with increased blood flow on Doppler, scrotal wall thickening, and possible hydrocele 1

Treatment Based on Diagnosis

For Epididymitis in Adolescents/Young Adults (<35 years)

Empiric therapy should be initiated before culture results are available:

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days (for gonococcal or chlamydial infection) 4
• Adjunctive measures: Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 4, 2

For Epididymitis in Adults (>35 years or Enteric Organisms)

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 4
• Same adjunctive measures as above 4, 2

Follow-Up for Epididymitis

• Reevaluate within 3 days if no improvement - consider alternative diagnosis including tumor, abscess, testicular cancer, or fungal infection 4
• Sex partner management: Partners within 60 days of symptom onset should be evaluated and treated 4
• Avoid sexual intercourse until both patient and partners complete therapy and are asymptomatic 4

Critical Pitfalls to Avoid

• Never assume trauma history excludes torsion - progressive worsening pain with a firm, tender testicle suggests torsion rather than simple injury 2
• Normal urinalysis does NOT exclude torsion or epididymitis 1, 2
• Do not start antibiotics empirically without ruling out torsion - this delays correct diagnosis and treatment 2
• Ultrasound has limitations - false-negative Doppler evaluations occur in up to 30% of cases, particularly with partial torsion or spontaneous detorsion 1
• Clinical presentations overlap significantly between torsion, epididymitis, and appendage torsion, making imaging essential when diagnosis is uncertain 1, 2
• In prepubertal boys, normally reduced intratesticular blood flow can mimic torsion on Doppler, leading to false-positive evaluations 1

Age-Specific Considerations

• Testicular torsion has a bimodal distribution with peaks in neonates and postpubertal boys, but is rare in patients over 35 years 1
• Epididymitis is overwhelmingly the most common cause in adults over 25 years 1
• Torsion of testicular appendage is the most common cause of testicular pain in prepubertal boys and is usually self-limiting 1