In a 24‑year‑old male with recurrent activity‑related testicular tenderness after heavy lifting, no current medications, and occasional tight underwear, what is the appropriate evaluation and initial management, including consideration of inguinal or femoral hernia versus epididymitis/orchitis?

Evaluation and Management of Activity-Related Testicular Pain in a Young Adult

Immediate Priority: Rule Out Testicular Torsion

This 24-year-old male with recurrent activity-related testicular tenderness requires urgent scrotal duplex Doppler ultrasound to exclude testicular torsion, particularly intermittent torsion, which can present with recurrent episodes of pain that spontaneously resolve. 1, 2

While the gradual onset and association with heavy lifting may suggest musculoskeletal or hernia-related pain, testicular torsion—including intermittent torsion—must be definitively excluded before pursuing other diagnoses, as delays beyond 6-8 hours can result in permanent testicular loss. 1, 2

Clinical Assessment: Key Distinguishing Features

Features Suggesting Intermittent Testicular Torsion

• Recurrent severe pain with rapid onset and spontaneous resolution is highly characteristic of intermittent torsion, with patients averaging 4.3 episodes before diagnosis (range 1-30). 3
• Pain triggered by physical activity (heavy lifting in this case) can precipitate torsion episodes. 3
• Horizontal lie of the testicle on physical examination is significantly associated with the bell-clapper deformity found in 82% of intermittent torsion cases and warrants surgical exploration even when the patient is pain-free at evaluation. 1, 3, 4
• Nausea or vomiting accompanies torsion in approximately 25% of cases. 1, 3
• Negative Prehn sign (pain not relieved by testicular elevation) supports torsion, though a positive Prehn sign does not exclude it. 1, 2

Features Suggesting Epididymitis

• Gradual onset of pain over hours to days with dysuria or urinary symptoms. 2
• Positive Prehn sign (pain relief with elevation) supports but does not confirm epididymitis. 2
• Fever and systemic symptoms are more common with infection. 5

Features Suggesting Inguinal Hernia

• Palpable bulge in the inguinal region that increases with Valsallis maneuver or standing. 6
• Reducible mass that disappears when supine.
• Pain typically worsens with lifting but does not present as acute testicular tenderness.

Diagnostic Workup

Immediate Imaging (Within 1-2 Hours)

Scrotal duplex Doppler ultrasound is the first-line study with sensitivity 69-96.8% and specificity 87-100% for testicular torsion. 1, 2, 5

Critical ultrasound components:

• Grayscale imaging to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity). 1, 2
• Color Doppler comparing perfusion between both testes, using the asymptomatic side as internal control. 1, 5
• Power Doppler for detecting low-flow states. 1, 5
• Spectral Doppler analysis of upper, mid, and lower testicular poles to detect regional flow variations. 1, 5

Key ultrasound findings by diagnosis:

Testicular torsion:

• Decreased or absent intratesticular blood flow 1, 2
• Whirlpool sign on grayscale 1, 2
• Enlarged, heterogeneous, hypoechoic testis 1
• Ipsilateral hydrocele and scrotal skin thickening 1

Epididymitis:

• Enlarged epididymis with increased color-Doppler flow (near 100% sensitivity) 2, 5
• Scrotal wall thickening and hydrocele 2, 5
• Concomitant orchitis in 20-40% of cases 5

Laboratory Studies

• Urinalysis to assess for pyuria (supports epididymitis), but normal UA does not exclude torsion. 1, 2
• Nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis if epididymitis suspected. 2
• Urine culture when enteric organisms suspected (age ≥35 or insertive anal intercourse). 2

Physical Examination for Hernia

• Palpate inguinal canal with patient standing and performing Valsalva maneuver.
• Assess for reducible bulge or palpable hernia sac.
• Note: Inguinal hernia can coexist with testicular pathology—one case series documented combined testicular torsion and inguinal hernia. 6

Critical Diagnostic Pitfalls

False-Negative Doppler Results

Doppler ultrasound has a ≥30% false-negative rate, particularly with:

• Partial or incomplete torsion where arterial flow persists because venous obstruction occurs first. 1, 2, 5
• Spontaneous detorsion followed by reactive hyperemia that mimics epididymitis. 5
• Very early presentation within first few hours when testis may appear normal. 1

If clinical suspicion remains high despite normal Doppler, proceed directly to surgical exploration. 1, 2, 5

Intermittent Torsion Considerations

• Patients may be completely pain-free at evaluation between episodes. 3, 4
• History of recurrent severe pain with rapid onset and resolution is highly characteristic. 3
• Horizontal testicular lie on examination mandates surgical exploration even with normal imaging. 3, 4

Management Algorithm

If Torsion Confirmed or Highly Suspected

1. Obtain urgent urological consultation immediately. 1, 2
2. Proceed to surgical exploration within 6-8 hours of symptom onset to prevent irreversible ischemic injury. 1, 2, 5
3. Do not delay surgery for imaging when clinical suspicion is high. 2, 5
4. Bilateral orchiopexy is performed during surgery to prevent contralateral torsion, as bell-clapper deformity is typically bilateral. 1, 3

If Intermittent Torsion Suspected (Recurrent Pain, Pain-Free at Evaluation)

1. Urgent scrotal ultrasound to assess testicular perfusion and identify horizontal lie. 3, 4
2. Surgical exploration with bilateral testicular fixation is recommended even if imaging is normal, as surgery results in complete symptom resolution in 97% of cases and prevents future testicular infarction. 3, 4
3. Mean number of episodes before surgery is 4.3, but surgery should not be delayed waiting for multiple recurrences. 3

If Epididymitis Confirmed

Age <35 years (presumed sexually transmitted):

• Ceftriaxone 250 mg IM single dose plus doxycycline 100 mg PO twice daily for 10 days. 2

Age ≥35 years or enteric pathogens likely:

• Ofloxacin 300 mg PO twice daily for 10 days or levofloxacin 500 mg PO once daily for 10 days. 2

Adjunctive measures:

• Bed rest, scrotal elevation, and analgesics until fever and inflammation resolve. 2
• Re-evaluate within 3 days if symptoms do not improve. 2

If Inguinal Hernia Confirmed Without Testicular Pathology

• Refer to general surgery for elective hernia repair.
• Counsel patient that heavy lifting should be avoided until surgical repair.
• Note: Ischemic orchitis is a rare but established complication after both open and laparoscopic inguinal hernia repair, typically presenting 2-3 days postoperatively. 7

Specific Recommendations for This Patient

Given this patient's presentation:

1. Perform urgent scrotal duplex Doppler ultrasound within 1-2 hours to exclude intermittent testicular torsion. 1, 2, 5

2. During physical examination, specifically assess:

   • Testicular axis (horizontal vs. vertical lie) 3, 4
   • Prehn sign (pain relief with elevation) 1, 2
   • Inguinal canal for hernia 6
   • Epididymal tenderness and swelling 2, 5

3. Obtain urinalysis to assess for infection. 2

4. If ultrasound shows normal perfusion but patient has history of recurrent severe pain with rapid resolution:

   • Consider diagnosis of intermittent torsion 3
   • Refer to urology for elective bilateral orchiopexy 3, 4
   • This prevents future testicular infarction and resolves symptoms in 97% of cases 3

5. If ultrasound and examination confirm epididymitis:

   • Initiate age-appropriate antibiotic therapy 2
   • Recommend scrotal support, rest, and NSAIDs 2
   • Avoid heavy lifting until symptoms resolve

6. If hernia is identified without testicular pathology:

   • Refer to general surgery for repair
   • Counsel regarding activity modification until surgical intervention

The history of severe testicular pain with heavy lifting that stopped him from working, now recurring with milder intensity, is concerning for intermittent torsion and warrants aggressive evaluation even if the patient is pain-free at presentation. 3, 4