Testicular Pain

Key considerations: Testicular torsion, Incarcerated inguinal hernia, Fournier gangrene

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history: Onset: sudden (torsion) vs gradual (epididymitis); Duration: <6 hours = best salvage window for torsion; Associated: nausea/vomiting (torsion), dysuria/frequency (epididymitis); Prior episodes (intermittent torsion); Sexual history: STI risk (epididymitis in young sexually active); Trauma; Age: torsion peaks in neonates and puberty (12-18 years); exam: Testicular position: high-riding, horizontal lie (torsion); Cremasteric reflex: absent in torsion; Prehn sign: relief with elevation suggests epididymitis (unreliable); Tenderness localization: diffuse (torsion) vs posterior/superior (epididymitis); Scrotal skin: erythema, edema, crepitus (Fournier gangrene); Blue dot sign: torsion of appendix testis (visible through scrotal skin); Inguinal exam: hernia; labs: Urinalysis: pyuria suggests epididymitis (but 25% of torsion patients have pyuria); GC/Chlamydia NAAT if STI risk; CBC if infection suspected; Lactate if Fournier gangrene suspected; imaging: Scrotal Doppler ultrasound: decreased or absent flow = torsion. Increased flow = epididymitis/orchitis; DO NOT delay surgery for ultrasound if torsion is clinically obvious (TWIST ≥5); bedside: TWIST score assessment; Attempt manual detorsion: "open the book" technique — rotate medially to laterally; Successful detorsion = immediate pain relief and return of blood flow — still requires surgery for orchiopexy

immediate: TWIST score assessment — ≥5 = go directly to OR; Manual detorsion attempt while arranging surgery (open the book); Urology consult immediately if torsion suspected; Pain control: ketorolac or morphine IV; general: Time is critical: salvage rates >90% if <6 hours, ~50% at 12 hours, <10% at 24 hours; If diagnosis uncertain and TWIST 2-4: urgent Doppler ultrasound; If torsion ruled out: treat underlying cause; specific: diagnosis: Testicular Torsion; steps: Immediate urology consult; Attempt manual detorsion ("open the book" — medial to lateral rotation); Surgical exploration and bilateral orchiopexy; Do NOT delay surgery for ultrasound if clinical diagnosis is clear; Bilateral orchiopexy because bell-clapper deformity is bilateral; diagnosis: Epididymitis; steps: If <35 years and sexually active: ceftriaxone 500mg IM + doxycycline 100mg BID x10 days; If >35 years or not sexually active: levofloxacin 500mg PO daily x10 days; Scrotal support, ice, NSAIDs; Follow-up in 1-2 weeks; diagnosis: Fournier Gangrene; steps: Surgical emergency — emergent debridement; Broad-spectrum antibiotics: vancomycin + piperacillin-tazobactam + clindamycin; ICU admission; High mortality if delayed

admit: Testicular torsion (OR); Fournier gangrene (OR + ICU); Incarcerated hernia requiring surgery; Severe epididymo-orchitis with systemic illness; discharge: Epididymitis with appropriate antibiotics and follow-up; Torsion of appendix testis (self-limiting — NSAIDs and rest); Simple hydrocele or varicocele with urology follow-up; consults: Urology: torsion (emergent), orchitis not improving, testicular mass; General surgery: incarcerated hernia, Fournier gangrene

TWIST ≥5: go directly to OR without waiting for ultrasound — every minute matters
Manual detorsion: "open the book" — rotate the affected testis from medial to lateral (like opening a book at the midline). Pain relief = successful
Salvage rate: >90% if detorsion within 6 hours, drops to <10% at 24 hours
Bell-clapper deformity is bilateral — the contralateral testis MUST be fixed (orchiopexy) at the same operation
Epididymitis in a prepubertal boy is unusual — always consider torsion first. In sexually active teens/adults, STI testing is mandatory

AUA Guidelines, Barbosa et al. TWIST Score J Urol 2013, Tintinalli Emergency Medicine 9th Edition. Last reviewed: 2024-11-01