In an adult male presenting with acute left testicular and spermatic cord pain, left lower‑quadrant abdominal discomfort, and dysuria, what is the differential diagnosis and immediate management?

Differential Diagnosis and Immediate Management of Left Testicular Pain with Dysuria

Immediate Priority: Rule Out Testicular Torsion

Testicular torsion must be excluded immediately as it is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular loss. 1, 2 Although torsion is more common in adolescents, it can occur at any age and should be considered even in adults presenting with acute scrotal pain. 1, 3

Key Clinical Features Distinguishing Torsion from Epididymitis

Testicular Torsion:

• Abrupt onset of severe unilateral pain developing within minutes 1, 2
• Pain radiating to lower abdomen or flank (occurs in 6.44% of adult cases as initial presentation) 4
• Negative Prehn sign - pain NOT relieved by elevating the testis 1, 5
• Nausea and vomiting commonly present 2, 6
• Normal urinalysis does NOT exclude torsion 1

Epididymitis (Most Likely in Your Case):

• Gradual onset of pain over hours to days 1
• Dysuria and urinary symptoms typically present 7
• Positive Prehn sign - pain relieved by testicular elevation 5
• May have abnormal urinalysis with pyuria 1
• Represents 600,000 cases annually in the United States 1

Diagnostic Algorithm

Step 1: Immediate Clinical Assessment

Assess the following critical features:

• Timing of pain onset - sudden (minutes) versus gradual (hours/days) 1
• Prehn sign - elevate the testis and assess pain relief 5
• Presence of urethral discharge or dysuria - suggests epididymitis 7
• Nausea/vomiting - more common with torsion 2, 6

Step 2: Urgent Doppler Ultrasound

Order immediate scrotal Doppler ultrasound if torsion cannot be clinically excluded. 1, 5 The examination should include:

• Grayscale assessment for testicular homogeneity and the "whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
• Color Doppler to compare blood flow between both testicles 1
• Power Doppler for enhanced detection of low-flow states 1

Critical Pitfall: Doppler has a 30% false-negative rate in partial torsion or early presentation. 1, 5 If clinical suspicion remains high despite normal Doppler, proceed directly to surgical exploration. 1

Step 3: Laboratory Evaluation

Obtain the following tests:

• Urinalysis - pyuria suggests epididymitis but normal UA does not exclude torsion 1
• Gram stain of urethral discharge - >5 PMNs per oil immersion field indicates urethritis 7
• Nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis 7
• Urine culture if enteric organisms suspected 7

Management Based on Diagnosis

If Testicular Torsion Confirmed or Highly Suspected:

Immediate urological consultation and surgical exploration within 6-8 hours. 1, 2 Do not delay surgery for imaging if clinical suspicion is high. 1, 5

If Epididymitis Diagnosed (Most Likely in Your Case):

For sexually active men <35 years (presumed gonococcal/chlamydial infection):

• Ceftriaxone 250 mg IM single dose 7
• PLUS Doxycycline 100 mg orally twice daily for 10 days 7

For men >35 years or enteric organism suspected:

• Ofloxacin 300 mg orally twice daily for 10 days 7
• OR Levofloxacin 500 mg orally once daily for 10 days 7

Adjunctive therapy for all epididymitis cases:

• Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 7

Follow-Up Requirements:

Reevaluate within 3 days if no improvement. 7 Persistent swelling and tenderness after completing antibiotics requires comprehensive evaluation for tumor, abscess, testicular cancer, tuberculosis, or fungal infection. 7

Additional Differential Considerations

Segmental testicular infarction:

• Presents with wedge-shaped avascular area on ultrasound 1
• Median age 37-38 years 1

Testicular tumor:

• Rare presentation as acute pain, but must be considered if ultrasound shows mass 8
• Physical examination may reveal hard, painless mass 8

Torsion of testicular appendage:

• More common in prepubertal boys but can occur in adults 1, 5
• Ultrasound shows normal testicular perfusion with localized hyperemia 5

Critical Clinical Pitfalls to Avoid

1. Never assume normal urinalysis excludes torsion - proceed with imaging if clinical suspicion exists 1
2. Do not rely solely on Doppler ultrasound - false-negative rate up to 30% in partial torsion 1, 5
3. Consider torsion even in adults - although rare over age 35, delayed diagnosis leads to testicular loss 1, 3
4. Always examine the testes in males with lower abdominal pain - 6.44% of adult torsion cases present with abdominal pain alone 4
5. Do not delay surgical exploration for imaging if clinical suspicion for torsion is high 1, 5