How should I evaluate and manage an 11-year-old boy with bilateral testicular pain and swelling?

Bilateral Testicular Pain and Swelling in an 11-Year-Old

Bilateral testicular torsion is exceedingly rare but life-threatening—this child requires immediate urological consultation and urgent scrotal ultrasound with Doppler to rule out simultaneous bilateral torsion, which demands surgical exploration within 6-8 hours to prevent permanent testicular loss. 1

Immediate Assessment Priority

The most critical first step is determining whether the testes are palpable or nonpalpable, as this fundamentally changes your diagnostic approach and urgency level:

If Testes Are Nonpalpable (Cannot Feel Either Testis)

• This is a medical emergency requiring immediate specialist consultation to evaluate for disorders of sex development, particularly congenital adrenal hyperplasia, which can present as life-threatening adrenal crisis with shock, hyponatremia, and hyperkalemia 2
• A phenotypic male with bilateral nonpalpable gonads may actually be a genetic female (46,XX) with severe congenital adrenal hyperplasia 2
• Do not delay—consult pediatric endocrinology and urology immediately 2

If Testes Are Palpable (Can Feel Both Testes in Scrotum)

Proceed with evaluation for acute scrotal pathology as outlined below.

Clinical Evaluation for Acute Bilateral Scrotal Pathology

Key distinguishing clinical features to assess immediately:

• Onset timing: Abrupt onset within minutes to hours suggests torsion (even bilateral), while gradual onset over days suggests epididymo-orchitis 1, 3
• Prehn sign: Pain that does NOT improve with testicular elevation (negative Prehn sign) strongly suggests torsion rather than epididymitis 1, 3
• Cremasteric reflex: Absence of cremasteric reflex is highly predictive of testicular torsion (p<0.0001) 4
• Associated symptoms: Nausea and vomiting are common with torsion 1, 5
• Systemic signs: Fever and urinary symptoms suggest infectious etiology (epididymo-orchitis) 1

Differential Diagnosis for Bilateral Presentation

Bilateral testicular torsion is extraordinarily rare but catastrophic if missed—always consider this first in any child with bilateral acute scrotal pain 1

Bilateral epididymo-orchitis (viral or bacterial):

• More common cause of bilateral symptoms in this age group 1, 3
• Gradual onset over 1-3 days 1
• May have fever, dysuria, or recent viral illness 3
• Ultrasound shows increased blood flow to epididymis and testis 1

Bilateral torsion of testicular appendages:

• Most common cause of testicular pain in prepubertal boys 1
• May present with "blue dot sign" (visible through scrotal skin in only 21% of cases) 1
• Ultrasound shows normal testicular perfusion with localized hyperemia 3

Trauma (if history supports this)

Diagnostic Imaging Protocol

Do NOT delay surgical consultation for imaging if clinical suspicion for torsion is high 1, 3

If clinical suspicion is intermediate, obtain urgent Duplex Doppler ultrasound with the following protocol 1:

• Grayscale examination: Look for enlarged heterogeneous testis, "whirlpool sign" of twisted spermatic cord (96% sensitivity), hydrocele, and scrotal wall thickening 1
• Color Doppler assessment: Compare testicular perfusion to contralateral side—decreased or absent flow suggests torsion 1
• Power Doppler: Particularly useful in prepubertal boys who normally have reduced intratesticular blood flow 1
• Spectral Doppler: Assess for diminished arterial velocity, decreased diastolic flow, or reversed diastolic flow 1

Critical Imaging Pitfalls

• False-negative rate is 30% or higher for Doppler ultrasound in partial torsion or early presentation 1, 5
• Prepubertal boys normally have reduced intratesticular blood flow, which can mimic torsion 1
• Never let a "normal" ultrasound override high clinical suspicion—proceed to surgical exploration if doubt remains 1

Management Algorithm

High Clinical Suspicion for Torsion (Any of the Following):

• Absent cremasteric reflex 4
• Negative Prehn sign 1, 3
• Abrupt onset severe pain with nausea/vomiting 1, 5
• Testicular retraction 4

→ Immediate urological consultation and surgical exploration without imaging delay 1, 3

Intermediate Suspicion:

→ Urgent Doppler ultrasound (within 1-2 hours) while keeping urology on standby 1

Ultrasound Shows Decreased/Absent Flow:

→ Immediate surgical exploration 1, 3

Ultrasound Shows Increased Flow (Hyperemia):

→ Likely epididymo-orchitis:

• Age-appropriate antibiotic therapy 3
• In prepubertal boys without sexual activity: consider enteric organisms or viral etiology 3
• Supportive care: scrotal elevation, rest, analgesics 1

Ultrasound Shows Normal Flow with Localized Hyperemia:

→ Likely bilateral torsion of testicular appendages:

• Conservative management with analgesics and observation 3
• Symptoms typically resolve in 3-10 days 6

Time-Critical Considerations

The 6-8 hour window is absolute: Testicular viability is severely compromised beyond this timeframe, with testicular salvage rates dropping precipitously after 12 hours 1, 5, 6

• All 11 cases of testicular torsion explored within 12 hours resulted in testicular salvage, while 4 of those presenting later required orchiectomy 6
• Delay in diagnosis beyond 6-8 hours significantly increases risk of permanent testicular loss 5

Common Clinical Pitfalls to Avoid

1. Assuming bilateral presentation excludes torsion—while rare, bilateral torsion does occur and is devastating if missed 1
2. Relying solely on ultrasound—30% false-negative rate means clinical judgment supersedes imaging 1, 5
3. Waiting for "business hours" or routine urology clinic—this is a true surgical emergency requiring immediate action 1, 3
4. Dismissing symptoms because the child is "too young" or "too old"—torsion has a bimodal distribution but can occur at any age 1, 5
5. Failing to recognize nonpalpable testes as a separate emergency—this requires immediate evaluation for disorders of sex development 2

Bottom Line

In an 11-year-old with bilateral testicular pain and swelling, assume the worst (bilateral torsion) until proven otherwise. Immediate urological consultation is mandatory, and surgical exploration should proceed if any doubt exists after clinical assessment ± imaging. The stakes are too high—bilateral testicular loss—to adopt a "wait and see" approach.