What is the appropriate evaluation and management for a male presenting with testicular ache?

Evaluation and Management of Testicular Ache

A male presenting with testicular ache requires immediate assessment to exclude testicular torsion, which is a surgical emergency requiring intervention within 6-8 hours to prevent permanent testicular loss. 1

Immediate Clinical Assessment

Critical Time-Sensitive Red Flags

• Sudden onset of severe unilateral pain with nausea/vomiting indicates testicular torsion until proven otherwise and requires immediate urological consultation without waiting for imaging if clinical suspicion is high. 1, 2
• Absent cremasteric reflex is the most accurate physical examination sign of testicular torsion. 3
• A high-riding testicle with abnormal lie suggests torsion. 4
• Negative Prehn sign (pain NOT relieved by testicular elevation) distinguishes torsion from epididymitis. 1

Age-Stratified Differential Diagnosis

• In adults over 25 years: Epididymitis/epididymo-orchitis is the most common cause, representing approximately 600,000 cases annually in the United States, characterized by gradual onset pain and positive Prehn sign. 1, 2
• In adolescents and young adults: Testicular torsion has a bimodal distribution with peaks in neonates and postpubertal boys, affecting 3.8 per 100,000 males under 18 years annually. 1, 4
• In prepubertal boys: Torsion of testicular appendage is most common, potentially showing the "blue dot sign" (visible in only 21% of cases). 1, 2

Diagnostic Algorithm

When to Proceed Directly to Surgery

• If clinical presentation strongly suggests torsion (sudden severe pain, absent cremasteric reflex, high-riding testis), proceed immediately to emergency urological consultation and surgical exploration without imaging. 1, 2 Delaying for imaging when clinical suspicion is high risks testicular loss. 2

When to Obtain Imaging First

• For intermediate clinical suspicion, obtain urgent Duplex Doppler ultrasound of the scrotum as the first-line imaging study (sensitivity 69-96.8%, specificity 87-100%). 1, 2

Key Ultrasound Findings by Diagnosis

Testicular Torsion:

• Decreased or absent blood flow to affected testicle compared to contralateral side 1
• "Whirlpool sign" of twisted spermatic cord (96% sensitivity) 1
• Enlarged heterogeneous testis appearing hypoechoic 1
• Ipsilateral hydrocele and scrotal wall thickening 1

Epididymitis/Epididymo-orchitis:

• Enlarged epididymis with increased blood flow on color Doppler (sensitivity near 100%) 1, 2
• Scrotal wall thickening 1
• Up to 20% concomitant orchitis rate 1

Critical Pitfall: False-negative Doppler evaluations occur in 30% or more of cases, particularly with partial torsion (≤450 degrees), spontaneous detorsion, or early presentation. 1 Power Doppler is more sensitive for low-flow states, especially in prepubertal boys. 1

Additional Diagnostic Testing

• Urinalysis and urine culture: Normal urinalysis does NOT exclude either testicular torsion or epididymitis. 1
• For suspected epididymitis in sexually active men under 35: Obtain urethral Gram stain (>5 PMNs per oil immersion field), plus culture or NAAT for N. gonorrhoeae and C. trachomatis. 5
• Serum tumor markers (AFP, hCG, LDH): Should be drawn prior to any treatment if a solid testicular mass is identified on ultrasound. 6

Management by Diagnosis

Testicular Torsion (Surgical Emergency)

• Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset to prevent permanent ischemic damage. 1, 2
• Surgical outcomes are significantly better when surgery occurs within 12 hours. 1
• Bilateral orchiopexy is mandatory during surgery to prevent contralateral torsion (82% have Bell clapper deformity). 1
• Orchiectomy rate is 42% in boys undergoing surgery for testicular torsion when diagnosis is delayed. 4

Epididymitis/Epididymo-orchitis

For sexually active men under 35 years or suspected STI:

• Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg orally twice daily for 10 days 5

For men over 35 years or suspected enteric organisms:

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 5

Supportive care for all:

• Bed rest, scrotal elevation, and analgesics until inflammation subsides 1

Torsion of Testicular Appendage

• Conservative management with analgesics and scrotal support is typically sufficient. 3
• Surgical treatment is not mandatory but hastens recovery. 3

Indeterminate Findings

• For patients with normal serum tumor markers and indeterminate findings on physical exam or ultrasound, repeat imaging in 6-8 weeks. 6

Special Considerations

Solid Testicular Mass

• Any solid mass in the testis identified by physical exam or imaging should be managed as malignant neoplasm until proven otherwise. 6
• Scrotal ultrasound with Doppler is mandatory. 6
• MRI should NOT be used as initial evaluation. 6

Bilateral or Alternating Testicular Pain

• Consider bilateral epididymitis (most common in sexually active men under 35), bilateral/sequential testicular torsion (2% of torsion cases), or viral orchitis. 5
• If testicular tumors are suspected, swelling and tenderness must be re-evaluated after completion of antimicrobial therapy. 5

Common Pitfalls to Avoid

• Never delay surgical exploration for imaging when clinical suspicion for torsion is high — testicular viability is compromised after 6-8 hours. 1, 2
• Do not rely solely on Doppler ultrasound to exclude torsion — false-negative rate approaches 30%. 1
• Do not assume epididymitis in prepubertal males — this diagnosis should be made with extreme caution in this age group. 3
• Trauma history can be a red herring — progressive worsening pain suggests torsion rather than simple traumatic injury. 2
• Starting antibiotics empirically when torsion is suspected delays correct diagnosis and treatment. 2