What are the possible causes of testicular pain and how should it be evaluated and managed?

Testicular Pain: Evaluation and Management

Immediate Action Required

Testicular torsion must be excluded first in any patient presenting with testicular pain, as this is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular loss. 1

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Emergency Red Flags Requiring Immediate Urological Consultation

• Sudden onset of severe scrotal pain – this presentation pattern strongly suggests testicular torsion and mandates urgent evaluation 1
• Negative Prehn sign (pain NOT relieved by elevating the testicle) – a key distinguishing feature of torsion 1
• Absent or decreased testicular blood flow on Doppler ultrasound – indicates vascular compromise requiring emergency surgery 1
• High clinical suspicion based on TWIST score – scores indicating intermediate to high risk warrant immediate imaging or surgical exploration 1

Critical time window: Surgical outcomes are significantly better when detorsion occurs within 6-8 hours of symptom onset, with testicular viability severely compromised beyond this window. 1

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Age-Stratified Differential Diagnosis

Adolescents and Young Adults (Most Common: Testicular Torsion)

• Testicular torsion has a bimodal distribution with peaks in neonates and postpubertal boys 1
• Presents with abrupt onset of severe pain, often with history of prior self-resolving episodes 1, 2
• Rare after age 35 years 1

Adults Over 25 Years (Most Common: Epididymitis)

• Epididymitis/epididymo-orchitis represents approximately 600,000 cases annually in the United States and is overwhelmingly the most common cause in adults 1
• Characterized by gradual onset of pain (versus sudden in torsion) 1
• May have abnormal urinalysis, though normal urinalysis does NOT exclude epididymitis 1

Prepubertal Boys (Most Common: Torsion of Testicular Appendage)

• Torsion of testicular appendage is the most common cause in this age group 1
• Usually self-limiting, resolving within 3-10 days 3
• "Blue dot sign" is pathognomonic but only seen in 21% of cases 1

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Diagnostic Algorithm

Step 1: Clinical Risk Stratification

• Assess onset and character of pain: Abrupt/severe suggests torsion; gradual suggests epididymitis 1
• Check Prehn sign: Negative (no relief with elevation) suggests torsion 1
• Consider patient age: Use age-stratified differential above 1
• Calculate TWIST score (for pediatric patients 3 months-18 years) to determine need for urgent imaging versus immediate surgical exploration 1

Step 2: Imaging Protocol (When Clinically Indicated)

Duplex Doppler ultrasound is the first-line imaging modality with sensitivity of 69-96.8% and specificity of 87-100% 1

Key ultrasound findings to assess:

For Testicular Torsion:

• Decreased or absent blood flow to affected testicle (compared to contralateral side as internal control) 1
• "Whirlpool sign" of twisted spermatic cord – most specific finding with 96% sensitivity 1
• Enlarged heterogeneous testis appearing hypoechoic 1
• Ipsilateral hydrocele and scrotal skin thickening 1

For Epididymitis:

• Increased blood flow to enlarged epididymis on color Doppler 1
• Scrotal wall thickening 1
• Up to 20% have concomitant orchitis 1

Technical Considerations:

• Power Doppler is more sensitive for low-flow states, particularly useful in prepubertal boys who normally have reduced intratesticular blood flow 1
• Perform spectral Doppler analysis of upper, mid, and lower poles to detect regional flow variations 1
• Always compare to contralateral testis as internal control 1

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Critical Diagnostic Pitfalls

False-Negative Doppler Results (Occur in 30% or More of Cases)

• Partial torsion (<450 degrees) may show persistent arterial flow because venous obstruction occurs first 1
• Spontaneous detorsion can restore flow temporarily 1
• Early presentation within first few hours may show normal-appearing testis 1

When clinical suspicion for torsion remains high despite normal Doppler, proceed immediately to surgical exploration without delay. 1

False-Positive Doppler Results

• Prepubertal boys and infants normally have reduced intratesticular blood flow, which can mimic torsion 1
• Always use contralateral testis for comparison 1

Overlapping Clinical Presentations

• Significant overlap exists between different causes of acute scrotal pain 1
• Both epididymitis and torsion can present with fever and pyuria 2
• Normal urinalysis does NOT exclude testicular torsion 1

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Management Algorithm

High Clinical Suspicion for Torsion (TWIST Score or Clinical Judgment)

Immediate urological consultation and surgical exploration within 6-8 hours – do NOT delay for imaging if suspicion is high 1

Surgical procedure includes:

• Detorsion of affected testis 1
• Assessment of testicular viability after detorsion 1
• Bilateral orchiopexy to prevent contralateral torsion (82% have Bell-clapper deformity predisposing to recurrence) 1

Confirmed Epididymitis/Epididymo-orchitis

• Bed rest and scrotal elevation 1
• Analgesics for pain control 1
• Antibiotic therapy based on age and risk factors 1
• In prepubertal boys: Cephalexin 25-50 mg/kg/day divided q6-8h for 10 days 3

Torsion of Testicular Appendage (Prepubertal Boys)

• Outpatient management with scrotal support 3
• Follow-up within 24-48 hours to confirm improvement 3
• Self-limiting, resolves in 3-10 days 3

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Additional Causes to Consider

Varicocele (2-10% Present with Pain)

• Dilatation of pampiniform plexus causing dull, aching, or throbbing pain 4
• Conservative management first; varicocelectomy resolves pain in 80% of carefully selected cases with clinically palpable varicocele 4

Segmental Testicular Infarction

• Classic wedge-shaped avascular area on ultrasound 1
• May also present as round lesions with variable Doppler flow 1
• Median age 37-38 years 1

Acute Idiopathic Scrotal Edema

• Rare, self-limiting condition primarily in prepubertal boys but can occur in adults 1
• Usually painless or minimally painful with marked scrotal wall thickening 1
• Diagnosis of exclusion 1

Tension Hydrocele (Rare Emergency)

• Large hydrocele causing compromised testicular perfusion 5
• Requires emergent operative drainage 5

Trauma

• Ultrasound may demonstrate testicular fracture, hematoceles, hemorrhage, or testicular infarction 2
• Corpus cavernosum rupture requires urgent surgical repair 3

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Special Populations

Sickle Cell Disease Patients

• Priapism (prolonged painful erection >4 hours) is a urological emergency requiring urgent treatment to prevent irreversible tissue damage 3
• Episodes <4 hours: Hydration and analgesia 3
• Episodes ≥4 hours: Emergency penile aspiration, saline irrigation, and potential alpha-adrenergic sympathomimetic injection 3

Pediatric Patients with Concerning Findings

• Mandatory reporting of suspected child abuse to appropriate authorities in all U.S. states 3
• STD screening indicated when genital trauma, clinical signs of STD, or disclosed history of abuse present 3
• Lichen sclerosus (porcelain-white plaques with ecchymosis) can mimic sexual abuse but conditions are not mutually exclusive 3