Acute Scrotal Pain in Adults

Quick Reference

Critical Alerts

Life-Threatening/Time-Critical Diagnoses:

• Testicular torsion: Surgical emergency with 4-6 hour window for optimal salvage (90-100% viability) [1,2]
• Fournier's gangrene: Necrotizing fasciitis of perineum/scrotum requiring immediate surgical debridement and broad-spectrum antibiotics [3]
• High-riding, horizontal testicle = Torsion until proven otherwise: Clinical diagnosis [1]
• Absent cremasteric reflex: 99% sensitivity for testicular torsion when combined with other clinical findings [4]
• DO NOT delay surgery for imaging if torsion highly suspected: Every hour of delay decreases salvage rate by ~7% [5]

Diagnostic Approach Algorithm

Acute Scrotal Pain
        ↓
Clinical Assessment
        ↓
    ┌───────────────────────┐
    │                       │
HIGH Suspicion          LOW Suspicion
for Torsion             for Torsion
    │                       │
    ↓                       ↓
IMMEDIATE SURGERY      Doppler Ultrasound
(Do NOT delay              │
 for imaging)              ↓
                    ┌──────┴──────┐
                    │             │
              Absent/↓ Flow   Normal/↑ Flow
                    │             │
                    ↓             ↓
            URGENT SURGERY    Epididymitis/
            (Torsion)         Other Diagnosis

Torsion vs Epididymitis: Clinical Differentiation

Emergency Differential Diagnosis

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Definition and Overview

Clinical Definition

Acute scrotal pain is defined as sudden-onset testicular or scrotal discomfort requiring urgent evaluation to exclude time-critical surgical emergencies, particularly testicular torsion. Testicular torsion involves rotation of the spermatic cord causing arterial occlusion and testicular ischemia, constituting a true urological emergency with irreversible ischemic damage occurring after 6-8 hours of symptom onset. [1,2]

The critical imperative is to distinguish testicular torsion (which requires immediate surgical detorsion and orchiopexy) from other causes of scrotal pain (most commonly epididymo-orchitis) which can be managed conservatively with antibiotics and supportive care.

Epidemiology

Testicular Torsion:

• Annual incidence: 3.8 per 100,000 males under 18 years; 1 per 100,000 in adults [1]
• Accounts for 10-15% of acute scrotal presentations in children, 3-5% in adults [10]
• Bimodal age distribution: Neonatal period and puberty (peak 12-18 years) [1]
• Can occur at any age, including elderly patients [11]
• Orchiectomy rate: 42% in patients undergoing surgery for testicular torsion [1]
• Decreased fertility documented in 36% of patients after unilateral torsion [12]

Epididymitis:

• Most common cause of acute scrotal pain in adults > 18 years [6]
• Bimodal distribution: Sexually active young adults (18-35 years) and older men (> 35 years) [6]
• Etiology varies by age:
  • less than 35 years: Sexually transmitted (Chlamydia trachomatis, Neisseria gonorrhoeae) in 80% [8]

  • 35 years: Urinary tract pathogens (E. coli, Pseudomonas) secondary to obstructive uropathy [6]

Fournier's Gangrene:

• Rare: 1.6 cases per 100,000 males per year [3]
• Mean age: 50-60 years [3]
• Mortality: 7.5-45% despite treatment [3]
• Risk factors: Diabetes mellitus (60%), alcohol abuse, immunosuppression [3]

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Anatomy and Pathophysiology

Normal Testicular Anatomy

Testicular Position and Suspension:

• Testes normally hang vertically within the scrotum, suspended by the spermatic cord
• Spermatic cord contains: testicular artery, pampiniform plexus, vas deferens, lymphatics, nerves
• Tunica vaginalis: Double-layered serous membrane surrounding testis and epididymis
• Normal attachment: Tunica vaginalis attaches to posterolateral testis and epididymis, preventing excessive mobility

Arterial Supply:

• Testicular artery (from abdominal aorta): Primary blood supply
• Artery to vas deferens (from inferior vesical artery): Collateral supply
• Cremasteric artery (from inferior epigastric): Minimal contribution
• Critical point: Testis relies predominantly on testicular artery; collaterals insufficient during acute torsion [7]

Bell-Clapper Deformity

Anatomic Predisposition to Torsion [7]:

• High attachment of tunica vaginalis to spermatic cord (instead of posterolateral testis)
• Creates "bell-clapper" configuration: Testis hangs freely within tunica like clapper in bell
• Allows testicle to rotate freely within scrotum
• Bilateral anomaly in 80%: Explains need for bilateral orchiopexy [7]
• Present in 12% of normal males but 70-90% of those with torsion [7]

Pathophysiology of Testicular Torsion

Mechanism of Injury:

1. Rotation of spermatic cord (typically 180-720 degrees)
2. Venous occlusion occurs first (lower pressure system): Congestion, edema, hemorrhagic infarction
3. Arterial occlusion follows: Complete ischemia
4. Progressive ischemic injury:
   • 0-4 hours: Reversible ischemia, minimal injury
   • 4-6 hours: Increasing ischemic damage, salvage rate 90-100% [2]
   • 6-12 hours: Salvage rate decreases to 50% [2]
   • 12-24 hours: Salvage rate 10-20% [2]

   • 24 hours: Salvage rate less than 10%, most require orchiectomy [2]

Direction of Rotation:

• Most common: "Inward" rotation (medial rotation of anterior surface)
• Right testis: Clockwise (viewed from below)
• Left testis: Counterclockwise (viewed from below)
• Degree of rotation: Typically 360-720 degrees (multiple rotations) [1]

Pathophysiology of Epididymitis

Mechanisms by Age Group [6]:

Age less than 35 Years (Sexually Transmitted):

• Retrograde ascent of urethral pathogens via vas deferens
• Chlamydia trachomatis: Most common (60%) [8]
• Neisseria gonorrhoeae: 20% [8]
• Often associated with urethritis
• May progress to orchitis (epididymo-orchitis) in 20-40%

Age > 35 Years (Urinary Pathogen-Related):

• Coliform bacteria (E. coli, Proteus, Klebsiella, Pseudomonas) [6]
• Associated with:
  • Bladder outlet obstruction (BPH)
  • Urinary tract instrumentation
  • Indwelling catheters
  • Anatomic abnormalities

Special Populations:

• Post-vasectomy: Chemical epididymitis from sperm extravasation
• Amiodarone therapy: Drug-induced epididymitis (5-10% of patients on chronic therapy) [13]
• Tuberculosis: Chronic granulomatous epididymitis (endemic areas)

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Clinical Presentation

History: Key Discriminating Features

Onset and Duration:

• Torsion: Sudden, maximal pain at onset; "I woke up with severe pain" [1]
• Epididymitis: Gradual onset over hours to days; progressive worsening [6]
• Appendix testis torsion: Gradual onset, initially mild, localized [14]

Pain Characteristics:

• Torsion: Severe, unilateral, constant; may radiate to lower abdomen/groin
• Epididymitis: Dull ache, gradually worsening; posterior/inferior scrotum
• Intermittent torsion: Recurrent episodes of sudden pain with spontaneous resolution (detorsion) [1]

Associated Symptoms:

• Nausea/vomiting: Present in 55% of torsion cases, uncommon in epididymitis [1]
• Fever: Rare in torsion initially; may occur with epididymitis/orchitis [6]
• Urinary symptoms: Absent in torsion; dysuria/frequency suggests epididymitis [6]
• Urethral discharge: Suggests STI-related epididymitis [8]

Precipitating Factors:

• Torsion: Often occurs during sleep, minor trauma, athletic activity; 50% have no identifiable trigger [1]
• Epididymitis: Sexual activity, UTI, recent instrumentation [6]

Risk Factors to Elicit:

Age-Related Considerations:

• less than 18 years: Torsion most likely (60-70% of acute scrotum) [10]
• 18-35 years: Epididymitis most common, but torsion still possible [6]

• 35 years: Epididymitis predominates; torsion rare but still must exclude [11]

Physical Examination

Systematic Approach:

Inspection

• Scrotal position and symmetry
• Skin changes: Erythema (epididymitis, advanced torsion), ecchymosis (trauma), necrosis (Fournier's)
• Swelling: Localized vs. diffuse
• High-riding testis: Shortened spermatic cord in torsion [1]
• Horizontal lie: Bell-clapper deformity [7]
• Blue dot sign: Visible torsed appendix testis through scrotal skin (prepubertal boys) [14]

Palpation

Cremasteric Reflex Assessment [4]

Technique:

• Patient standing or supine
• Stroke or pinch medial thigh (superior to inferior)
• Normal response: Ipsilateral testicle rises due to cremasteric muscle contraction

Interpretation:

• Absent reflex: 99% sensitivity, 87% specificity for torsion [4]
• Present reflex: Does NOT exclude torsion (1% false negative rate) [4]
• Bilateral absence: Non-specific (obesity, prior surgery, neurological disease)
• Limitations: Difficult in very young children, obese patients, severe pain/swelling

Prehn Sign

• Technique: Manual elevation of affected hemiscrotum
• Positive (pain relief): Suggests epididymitis
• Negative (no relief or worsening): Suggests torsion
• Reliability: Poor; not recommended as sole discriminator [15]

Inguinal Examination

• Palpate external inguinal ring: Incarcerated hernia
• Transillumination: Hydrocele (light transmission), hematocele/tumor (no transmission)

Systemic Assessment

• Vital signs: Fever, tachycardia (Fournier's, severe orchitis)
• Abdominal exam: Lower abdominal tenderness common with torsion
• Perineal/perianal exam: Erythema, induration, crepitus (Fournier's) [3]

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Red Flags and Clinical Predictors

Absolute Indications for Immediate Surgical Exploration

Do NOT delay for imaging:

1. Classic torsion presentation: Sudden onset + high-riding horizontal testis + absent cremasteric reflex [1,4]
2. High clinical suspicion in appropriate age group (adolescent/young adult)
3. Intermittent torsion history: Recurrent self-limited episodes mandate elective bilateral orchiopexy [1]
4. Inconclusive or unavailable imaging with moderate-high clinical suspicion
5. Fournier's gangrene: Crepitus, skin necrosis, systemic toxicity [3]

Clinical Prediction Models

TWIST Score (Testicular Workup for Ischemia and Suspected Torsion) [16]:

Score Interpretation:

• 0-2 points: Low risk (torsion unlikely, less than 10% probability)
• 3-4 points: Intermediate risk (requires imaging)
• 5-7 points: High risk (> 80% probability, proceed to surgery)

Limitations: Validated in pediatric populations; adult data limited [16]

Time-Critical Benchmarks

Testicular Salvage Rates by Duration [2,5]:

Key Point: Pain duration > 6 hours does NOT exclude torsion or preclude surgery; salvage remains possible up to 24+ hours [2]

Fournier's Gangrene Red Flags [3]

Clinical Signs Requiring Emergency Surgery:

• Skin findings: Erythema, edema, blisters, crepitus, black necrotic patches
• Systemic toxicity: Fever > 38.5°C, tachycardia > 120, hypotension
• Laboratory: WBC > 15,000, creatinine > 1.5, lactate > 2.5 (LRINEC score > 6) [17]
• Imaging (CT): Subcutaneous gas, fascial thickening, fluid collections

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Investigations

Laboratory Studies

Urinalysis and Urine Culture [6]:

• Epididymitis: Pyuria (> 10 WBC/hpf), bacteriuria
• Torsion: Typically normal (pyuria in less than 10%)
• Sensitivity: 86% for epididymitis, but 14% false negative rate [6]
• Recommendation: Obtain in all patients but do NOT exclude torsion based on normal urinalysis

Nucleic Acid Amplification Testing (NAAT) [8]:

• Indication: All sexually active males less than 35 years with suspected epididymitis
• Samples: First-void urine or urethral swab
• Pathogens: Chlamydia trachomatis, Neisseria gonorrhoeae
• Turnaround: 1-3 days (treat empirically, do not wait for results)

Complete Blood Count:

• Limited utility for diagnosis
• Leukocytosis may occur in epididymitis, orchitis, Fournier's gangrene
• Normal WBC does NOT exclude torsion

Serum Tumor Markers (if tumor suspected) [18]:

• Indications: Palpable testicular mass, heterogeneous echotexture on ultrasound
• Markers: AFP (alpha-fetoprotein), β-hCG (human chorionic gonadotropin), LDH
• Sensitivity: 51% (AFP), 40% (β-hCG) for testicular cancer
• Note: Do NOT delay torsion surgery for tumor markers

Imaging

Color Doppler Ultrasound [9,19]

Indications:

• Uncertain diagnosis (intermediate clinical suspicion)
• Atypical presentation
• Chronic or recurrent symptoms

Technique:

• Gray-scale + color Doppler + spectral Doppler
• Bilateral comparison essential
• High-frequency linear transducer (7-15 MHz)

Findings by Diagnosis:

Diagnostic Performance for Torsion [9,19]:

• Sensitivity: 88.9-100%
• Specificity: 98.8-100%
• Positive Predictive Value: 100%
• Negative Predictive Value: 97.5%

Limitations:

• Operator-dependent: Experience critical for accurate interpretation
• Early torsion (less than 4 hours): Flow may still be present (intermittent torsion, incomplete torsion)
• Late torsion: Hyperemia from reperfusion or reactive inflammation may mimic epididymitis
• Spontaneous detorsion: Resumed flow with viable testis [9]
• False negatives: 1-2% of cases [19]

Critical Point: NEVER delay surgery for imaging if clinical suspicion is high [1]

Computed Tomography (CT)

Indications:

• Suspected Fournier's gangrene: Extent assessment for surgical planning [3]
• Testicular tumor staging (if confirmed on ultrasound)

NOT indicated for acute scrotal pain workup unless specific indication above

Nuclear Scintigraphy (Historical)

Technetium-99m pertechnetate scrotal scan:

• Historic modality: High sensitivity (90-100%) for torsion
• Current status: Largely replaced by Doppler ultrasound (faster, more available)
• Finding in torsion: "Cold spot" (absent tracer uptake)
• Limitations: Time-consuming (30-60 minutes), requires nuclear medicine availability [9]

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Diagnosis and Differential Diagnosis

Diagnostic Algorithm

Step 1: Clinical Assessment

• History (onset, duration, associated symptoms)
• Physical examination (position, cremasteric reflex, tenderness pattern)
• Calculate clinical probability (TWIST score if applicable)

Step 2: Risk Stratification

Step 3: Imaging (if indicated)

• Color Doppler ultrasound
• Interpret in clinical context (imaging does NOT override high clinical suspicion)

Step 4: Definitive Management

• Surgical exploration for torsion (or high suspicion despite imaging)
• Conservative management with antibiotics for epididymitis
• Supportive care for appendix testis torsion

Comprehensive Differential Diagnosis

Testicular Torsion [1,2,7]

Intravaginal Torsion (most common in adolescents/adults):

• Spermatic cord twists within tunica vaginalis
• Associated with bell-clapper deformity
• Peak age: 12-18 years (can occur any age)

Extravaginal Torsion (neonates):

• Entire testis and tunica vaginalis twist
• Occurs before tunica vaginalis fuses to scrotal wall
• Often prenatal; presents with firm, non-tender scrotal mass at birth

Intermittent Torsion:

• Recurrent episodes of acute pain with spontaneous resolution (detorsion)
• History of multiple self-limited episodes
• High risk of complete torsion; elective bilateral orchiopexy recommended [1]

Epididymo-orchitis [6,8]

Acute Epididymitis:

• Inflammation of epididymis
• May progress to orchitis (20-40%)
• Age-specific etiologies (STI less than 35 years, enteric > 35 years)

Chronic Epididymitis:

• Duration > 6 weeks
• Causes: Post-infectious, granulomatous (TB), chemical (post-vasectomy), idiopathic

Orchitis (isolated testicular inflammation):

• Viral: Mumps (most common), HIV, coxsackie
• Bacterial: Secondary to epididymitis or hematogenous spread
• Granulomatous: Tuberculosis, sarcoidosis

Torsion of Testicular Appendages [14]

Appendix Testis (most common, 90%):

• Müllerian duct remnant at upper pole of testis
• Peak age: 7-14 years (prepubertal)
• Blue dot sign: Visible ischemic appendage through scrotal skin

Appendix Epididymis:

• Wolffian duct remnant at head of epididymis
• Less common than appendix testis torsion

Fournier's Gangrene [3]

Necrotizing Fasciitis of perineum/scrotum:

• Polymicrobial: Aerobes (E. coli, Klebsiella) + anaerobes (Bacteroides, Clostridium)
• Rapidly progressive (hours to days)
• Mortality: 7.5-45% despite aggressive treatment

Predisposing Factors:

• Diabetes mellitus (60% of cases)
• Perianal abscess, urethral injury, perineal trauma
• Immunosuppression (HIV, steroids, chemotherapy)

Traumatic Causes

Testicular Rupture [20]:

• Blunt trauma → tunica albuginea tear → extrusion of seminiferous tubules
• Requires surgical exploration and repair (less than 72 hours for optimal salvage)
• Ultrasound: Irregular testicular contour, heterogeneous echotexture, hematocele

Hematocele:

• Blood in tunica vaginalis space
• Post-traumatic or spontaneous (anticoagulation, tumor)

Scrotal Hematoma:

• Blood in scrotal wall/dartos layer
• Usually conservative management unless expanding

Incarcerated Inguinal Hernia

• Bowel herniated into scrotum, cannot be reduced
• May cause testicular ischemia from cord compression
• Requires urgent surgical reduction/repair

Testicular Tumor [18]

• 80% painless, but 20% present with acute pain (hemorrhage, infarction, rapid growth)
• Peak age: 20-40 years
• Firm, non-tender mass on palpation
• Ultrasound: Hypoechoic, hypervascular mass
• Tumor markers: AFP, β-hCG, LDH

Other Causes

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Management

Testicular Torsion

Immediate Surgical Exploration [1,2]

Indications:

• High clinical suspicion (sudden onset, high-riding testis, absent cremasteric reflex)
• Doppler ultrasound showing absent/decreased flow
• Any uncertainty when torsion cannot be excluded

Surgical Procedure:

1. Scrotal Exploration (midline raphe or transverse incision):

   • Deliver testis through tunica vaginalis
   • Assess degree of torsion (typically 360-720°)
   • Detorsion: Untwist in appropriate direction

2. Viability Assessment:

   • Observe for 10-15 minutes after detorsion
   • Signs of viability: Color return (from blue/black to pink), return of arterial pulsation, bleeding from tunica albuginea puncture
   • If viable: Orchiopexy (fixation with 3-point non-absorbable sutures)
   • If non-viable: Orchiectomy (necrotic testis may trigger autoimmune orchitis in contralateral testis) [21]

3. Contralateral Orchiopexy:

   • ALWAYS performed due to bilateral bell-clapper deformity (80% bilateral) [7]
   • Reduces contralateral torsion risk from 1 in 4,000 to near-zero

Timing:

• Target: Surgery within 6 hours of symptom onset (90-100% salvage) [2]
• Reality: Salvage possible even > 12-24 hours; never delay if diagnosis made late [5]
• Benchmark: Door-to-OR time less than 60 minutes for high suspicion cases

Manual Detorsion (Bedside) [1]

Indications:

• Surgical delay anticipated (rural/remote settings, OR unavailability)
• Bridge to definitive surgery (orchiopexy still required regardless of success)

Technique:

"Open the Book" Method:

1. Right testis: Rotate counterclockwise (medial to lateral) when viewed from patient's perspective
2. Left testis: Rotate clockwise (medial to lateral) when viewed from patient's perspective
3. Rotate 180-360° (sometimes 540-720° if multiple rotations present)
4. Success indicators: Immediate pain relief, testis assumes normal position

Pearls:

• Consider analgesia or procedural sedation
• May require multiple attempts (1-3 rotations)
• If pain worsens, rotate in opposite direction
• Success rate: 26-80% (variable by operator experience) [1]

Critical Point: Manual detorsion does NOT replace surgical orchiopexy; elective bilateral orchiopexy required within days [1]

Epididymo-orchitis

Antibiotic Therapy [8,22]

Age less than 35 Years or Sexually Active (STI coverage):

First-Line:

• Ceftriaxone 500 mg IM × 1 dose (1 g if weight > 150 kg) PLUS
• Doxycycline 100 mg PO BID × 10 days

Alternative (cephalosporin allergy):

• Cefixime 800 mg PO × 1 dose PLUS
• Doxycycline 100 mg PO BID × 10 days

If Gonorrhea Resistance Suspected:

• Gentamicin 240 mg IM × 1 dose PLUS
• Azithromycin 2 g PO × 1 dose

Age > 35 Years or Enteric Pathogen Suspected:

First-Line:

• Levofloxacin 500 mg PO daily × 10 days OR
• Ciprofloxacin 500 mg PO BID × 10 days

Alternative (fluoroquinolone contraindication):

• Trimethoprim-sulfamethoxazole DS (160/800 mg) PO BID × 10 days

Severe Epididymo-orchitis or Abscess Formation (inpatient):

• Ceftriaxone 1-2 g IV daily OR
• Ampicillin-sulbactam 3 g IV q6h PLUS
• Doxycycline 100 mg IV/PO BID

Supportive Care [6]

Partner Management and STI Counseling [8]

If STI-Related:

• Sexual partners within 60 days should be evaluated and treated
• Expedited partner therapy (EPT): Provide prescription for partner
• Abstain from sexual activity until patient and partner complete treatment
• Retest for STI in 3 months (high reinfection rate)
• HIV and syphilis testing recommended

Follow-Up

• Reassess in 3 days if no improvement or worsening
• Re-evaluate for torsion if pain worsens acutely
• Ultrasound if not improving at 1 week (exclude abscess, tumor)
• Urology referral if recurrent epididymitis, persistent symptoms > 6 weeks, or palpable mass

Torsion of Appendix Testis [14]

Conservative Management

Indications:

• Clinical diagnosis or ultrasound confirmation
• Torsion definitively excluded

Treatment:

• NSAIDs: Ibuprofen 400-600 mg PO q6h for 7-10 days
• Scrotal support: Athletic supporter
• Activity restriction: Avoid strenuous activity for 1-2 weeks
• Natural history: Symptoms resolve in 7-14 days as appendage undergoes aseptic necrosis and resorption

Surgical Excision (rarely needed):

• Persistent pain > 2 weeks
• Inability to exclude testicular torsion clinically

Fournier's Gangrene [3]

Emergency Management

Immediate Interventions (within 1-2 hours of diagnosis):

1. Aggressive Fluid Resuscitation:

   • 2-4 L crystalloid initially
   • Target MAP > 65 mmHg, urine output > 0.5 mL/kg/hr

2. Broad-Spectrum Antibiotics (before surgery):

   • Piperacillin-tazobactam 4.5 g IV q6h PLUS
   • Clindamycin 600-900 mg IV q8h (toxin suppression) PLUS
   • Vancomycin 15-20 mg/kg IV q8-12h (MRSA coverage)

   Alternative:

   • Meropenem 1 g IV q8h + Clindamycin 600-900 mg IV q8h

3. Emergent Surgical Debridement:

   • Wide excision of all necrotic tissue (skin, subcutaneous fat, fascia)
   • Extends to bleeding, viable tissue margins
   • May require multiple staged debridements (every 12-24 hours)
   • Orchiectomy rarely needed: Testis usually spared (separate blood supply)

4. ICU Admission:

   • Hemodynamic monitoring
   • Sepsis management
   • Nutritional support

Adjunctive Therapies (variable evidence):

• Hyperbaric oxygen: May reduce mortality and debridement number [3]
• Vacuum-assisted closure (VAC therapy): After debridement, facilitates wound healing

Reconstruction:

• Delayed primary closure or skin grafting after infection controlled
• Often requires plastic surgery consultation

Testicular Rupture [20]

Surgical Exploration (within 72 hours):

• Evacuate hematoma
• Debride non-viable seminiferous tubules
• Primary repair of tunica albuginea (if less than 50% parenchymal loss)
• Orchiectomy if > 50% parenchymal destruction

Outcomes:

• Early repair (less than 72 hours): 80-90% testicular salvage
• Delayed repair: 45% salvage, higher infection/atrophy rate

Testicular Tumor [18]

Urgent Urology Referral:

• Inguinal orchiectomy (NOT trans-scrotal biopsy)
• Tumor markers: AFP, β-hCG, LDH
• Staging CT chest/abdomen/pelvis
• Multidisciplinary oncology management

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Disposition and Follow-Up

Emergency Department Disposition

Admission Criteria

Mandatory Admission:

• Testicular torsion (emergent surgery)
• Fournier's gangrene (emergent surgery + ICU)
• Testicular abscess (IV antibiotics, possible drainage)
• Severe epididymo-orchitis with systemic toxicity (fever > 38.5°C, unable to tolerate PO)
• Testicular rupture (urgent surgery)
• Unable to definitively exclude torsion (observation, serial exams, urology consultation)

Discharge Criteria

Safe for Discharge:

• Epididymitis diagnosis confirmed, torsion excluded
• Pain controlled with oral analgesia
• Able to tolerate oral antibiotics
• Reliable patient with follow-up arranged
• Adequate patient education provided (return precautions)

Return Precautions

Instruct patient to return immediately if:

• Sudden worsening of pain (suggests torsion)
• Fever > 38.5°C (101.3°F)
• Inability to urinate
• Spreading redness, swelling, or skin changes (Fournier's)
• No improvement after 48-72 hours of antibiotics
• New testicular mass or firmness

Follow-Up Schedule

Epididymo-orchitis:

• 3 days: Phone or clinic follow-up to ensure clinical improvement
• 1-2 weeks: If not resolved, repeat examination and consider ultrasound
• STI testing: Retest in 3 months (high reinfection rate) [8]

Post-Orchiopexy (Torsion):

• 1-2 weeks: Wound check, pain assessment
• 3 months: Testicular examination, discuss fertility implications
• Annual: Consider testicular ultrasound (atrophy, late complications)

Post-Orchiectomy:

• 1-2 weeks: Wound check
• 3-6 months: Consider testicular prosthesis for cosmesis
• Discuss: Testosterone levels, fertility (if bilateral or remaining testis compromised)

Urology Referral Indications

Emergent (same day):

• Suspected testicular torsion
• Testicular rupture
• Fournier's gangrene

Urgent (within 1 week):

• Testicular mass or tumor
• Testicular abscess
• Recurrent epididymitis
• Intermittent torsion history

Routine:

• Chronic scrotal pain (> 6 weeks)
• Hydrocele, spermatocele requiring treatment
• Persistent symptoms despite appropriate antibiotic therapy

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Special Populations and Considerations

Neonatal Torsion

Presentation:

• Firm, painless scrotal mass at birth or within first month
• Typically extravaginal torsion (prenatal occurrence)
• Discolored hemiscrotum (red/blue/black)

Management:

• Controversial: Emergent vs. semi-urgent vs. elective surgery
• Most advocate urgent exploration (within 24 hours) to:
  • Confirm diagnosis (rule out tumor, hematoma)
  • Perform contralateral orchiopexy (12% risk of contralateral torsion) [23]
• Salvage rate low (less than 10%) if prenatal onset

Elderly Patients

Special Considerations:

• Torsion rare but still possible (documented cases in 70s-80s) [11]
• Epididymitis more common; often secondary to BPH/urinary retention
• Higher index of suspicion for tumor (second peak incidence > 60 years)
• Comorbidities may complicate surgical management

Immunocompromised Patients

Expanded Differential:

• Opportunistic infections (CMV, fungal epididymo-orchitis)
• Higher risk of Fournier's gangrene
• Aggressive empiric antibiotics while awaiting cultures

Post-Vasectomy

Epididymitis:

• Chemical epididymitis (sperm granuloma)
• Usually occurs 1-4 weeks post-procedure
• Management: NSAIDs, supportive care; antibiotics if bacterial superinfection suspected

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Prognosis and Complications

Testicular Torsion

Salvage Rates [2,5]:

• less than 6 hours: 90-100% salvage
• 6-12 hours: 50% salvage
• 12-24 hours: 10-20% salvage

• 24 hours: less than 10% salvage

Long-Term Complications:

• Testicular atrophy: 40-70% of salvaged testes develop some degree of atrophy [12]
• Impaired fertility: Decreased sperm count in 36% after unilateral torsion [12]
  • "Mechanism: Autoimmune orchitis (anti-sperm antibodies), damage to blood-testis barrier"
  • Contralateral testis may be affected (10-30%) [21]
• Chronic pain: 10-15% experience persistent discomfort
• Recurrent torsion: less than 1% if adequate orchiopexy performed; higher if inadequate fixation
• Cosmetic concerns: Testicular atrophy, asymmetry

Fertility Counseling:

• Majority retain normal fertility with unilateral torsion and contralateral normal testis
• Sperm banking not routinely recommended but can discuss if bilateral torsion or solitary testis

Epididymo-orchitis

Acute Complications [6]:

• Testicular abscess: 3-5% (requires drainage or orchiectomy)
• Testicular infarction: Rare (less than 1%) from vascular compromise
• Chronic epididymitis: 10-15% develop persistent symptoms > 6 weeks

Long-Term Sequelae:

• Impaired fertility: 10-15% with chronic epididymitis (epididymal obstruction)
• Chronic scrotal pain: 5-10%
• Recurrent epididymitis: Higher risk if underlying urological abnormality

Fournier's Gangrene

Mortality [3]:

• Overall: 7.5-45% (average 20-30%)
• Higher mortality with: Delayed diagnosis, extensive disease, immunosuppression, age > 60 years

Morbidity:

• Multiple debridements required: Average 3-5 procedures
• Prolonged hospitalization: Mean 2-4 weeks
• Long-term reconstruction: Skin grafting, flap coverage
• Functional impairment: Sexual dysfunction, voiding difficulty, cosmetic defects

LRINEC Score (Laboratory Risk Indicator for Necrotizing Fasciitis) [17]:

• Predicts severity and mortality
• Score ≥6: High risk for necrotizing fasciitis
• Components: CRP, WBC, hemoglobin, sodium, creatinine, glucose

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Quality Metrics and Documentation

Key Performance Indicators

Essential Documentation Elements

History:

• Onset and duration of pain (specific time)
• Pain character and progression
• Associated symptoms (nausea, vomiting, fever, dysuria, discharge)
• Prior episodes (intermittent torsion)
• Sexual history, risk factors

Physical Examination:

• Testicular position (high-riding vs. normal)
• Testicular lie (horizontal vs. vertical)
• Cremasteric reflex (present vs. absent, bilateral assessment)
• Testicular vs. epididymal tenderness
• Prehn sign (if assessed)
• Scrotal skin changes

Diagnostic Studies:

• Urinalysis results
• Doppler ultrasound findings (flow present/absent, increased/decreased)
• Time of imaging and interpretation

Management:

• Time of urology consultation
• Time of surgical decision
• Door-to-OR time
• Antibiotics prescribed (regimen, dosing)

Disposition:

• Follow-up arranged
• Return precautions provided
• Partner notification/treatment (if STI)

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Patient Education

Testicular Torsion Post-Operative

Condition Explanation: "Your testicle twisted on the cord that supplies blood to it, like a rope being twisted. We had to do surgery to untwist it and stitch it in place so it doesn't happen again. We also stitched the other testicle in place to prevent the same problem on that side."

Post-Operative Instructions:

• Scrotal support for 1-2 weeks (athletic supporter)
• Ice packs for first 48 hours (20 min on/off)
• Avoid heavy lifting, straining, strenuous activity for 2-4 weeks
• May shower after 48 hours (pat incision dry)
• Expect swelling, bruising (resolves in 2-4 weeks)

Warning Signs (return to ED):

• Increasing pain not controlled by medications
• Fever > 38.5°C (101.3°F)
• Wound redness, drainage, or opening
• Inability to urinate

Long-Term:

• Monthly testicular self-examination (check for masses, asymmetry, new lumps)
• Fertility typically normal, but discuss if planning family in future

Epididymitis Discharge Instructions

Condition Explanation: "You have an infection of the epididymis, the tube that carries sperm from your testicle. This is treated with antibiotics and supportive care. It is NOT the same as testicular torsion (twisted testicle), which is a surgical emergency."

Medication Instructions:

• Complete full antibiotic course (10 days) even if feeling better
• Take doxycycline with food to avoid nausea
• If prescribed for sexually transmitted infection, sexual partners need treatment

Home Care:

• Scrotal support (athletic supporter or supportive underwear)
• Ice packs 20 min on/off for first 48 hours
• Ibuprofen or naproxen for pain/inflammation
• Rest, elevate scrotum when lying down
• Avoid sexual activity until completing antibiotics and pain-free

Follow-Up:

• Expect improvement in 2-3 days (may take 1-2 weeks to fully resolve)
• Return if no improvement in 3 days or worsening at any time
• STI testing in 3 months (if STI-related)

Partner Notification (if STI):

• Sexual partners within 60 days should be tested and treated
• Abstain from sex until both you and partner complete treatment

Testicular Self-Examination

When to Perform:

• Monthly, after warm shower (scrotum relaxed)
• Recommended for all men ages 15-55

Technique:

1. Examine each testicle separately
2. Roll testicle between thumb and fingers
3. Feel for lumps, swelling, or changes in consistency
4. Normal: Firm, smooth, oval shape; epididymis (soft, rope-like structure on back/top)

What to Report:

• New lump or mass (hard, painless)
• Swelling or enlargement
• Pain or heaviness
• Changes from prior self-exams

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Key Clinical Pearls

Diagnostic Pearls

1. "Torsion is a clinical diagnosis": Do NOT delay surgery for imaging if high suspicion [1]
2. Absent cremasteric reflex = Torsion until proven otherwise (99% sensitivity) [4]
3. High-riding, horizontal testis = Torsion: Classic finding [1]
4. Sudden onset in adolescent male = Torsion: Most common scenario [1]
5. Doppler flow does NOT exclude torsion: Intermittent/incomplete torsion may have flow [9]
6. Normal urinalysis does NOT exclude epididymitis: 14% false negative [6]
7. Blue dot sign = Appendix testis torsion: Visible ischemic appendage (prepubertal) [14]
8. Fournier's gangrene = Crepitus + systemic toxicity: Surgical emergency [3]

Treatment Pearls

1. Manual detorsion "opens the book": Medial to lateral rotation (buys time but does NOT replace orchiopexy) [1]
2. Bilateral orchiopexy is MANDATORY: Bell-clapper deformity is bilateral in 80% [7]
3. Epididymitis age less than 35 = STI: Ceftriaxone + doxycycline [8]
4. Epididymitis age > 35 = Enteric: Fluoroquinolone (levofloxacin) [6,22]
5. Pain > 24 hours does NOT preclude surgery: Salvage still possible [5]
6. Appendix testis torsion is self-limited: Conservative management, NSAIDs [14]
7. Fournier's requires IMMEDIATE debridement: Door-to-OR less than 2 hours [3]

Disposition Pearls

1. When in doubt, explore: Negative exploration better than missed torsion (testicular loss)
2. Never discharge suspected torsion without urology consultation: Medicolegal and patient safety imperative
3. Epididymitis can be discharged with close follow-up (if torsion excluded, antibiotics prescribed, pain controlled)
4. All testicular complaints need follow-up: Tumor may present with acute pain [18]
5. Document cremasteric reflex assessment: Medicolegal protection and clinical standard [4]

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References

1. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840. PMID: 24364548

2. Ciftci AO, Senocak ME, Tanyel FC, Buyukpamukcu N. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 2004;14(5):333-338. doi:10.1055/s-2004-820984

3. Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS. Fournier's gangrene: current practices. ISRN Surg. 2012;2012:942437. doi:10.5402/2012/942437

4. Boettcher M, Krebs T, Bergholz R, Wenke K, Aronson D, Reinshagen K. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int. 2013;112(8):1201-1206. doi:10.1111/bju.12229

5. Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int. 2003;92(3):200-203. doi:10.1046/j.1464-410x.2003.04307.x

6. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009;79(7):583-587. PMID: 19378875

7. Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. 1994;44(1):114-116. doi:10.1016/s0090-4295(94)80022-8

8. Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1

9. Zhao LC, Lautz TB, Meeks JJ, Maizels M. Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures toward improving the quality of care. J Urol. 2011;186(5):2009-2013. doi:10.1016/j.juro.2011.07.024

10. Bayne AP, Madden-Fuentes RJ, Jones EA, Cisek LJ, Gonzales ET Jr, Reaney D, et al. Factors associated with delayed treatment of acute testicular torsion--do demographics or hospital characteristics matter? J Urol. 2010;184(4 Suppl):1743-1747. doi:10.1016/j.juro.2010.03.073

11. DaJusta DG, Granberg CF, Villanueva C, Baker LA. Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol. 2013;9(6 Pt A):723-730. doi:10.1016/j.jpurol.2012.08.012

12. Anderson MJ, Dunn JK, Lipshultz LI, Coburn M. Semen quality and endocrine parameters after acute testicular torsion. J Urol. 1992;147(6):1545-1550. doi:10.1016/s0022-5347(17)37614-5

13. Akbarzadeh A, Daneshpajooh A, Mirzaei M, Davoodabadi A, Mokhtari G. Acute epididymitis secondary to amiodarone: a case report and literature review. Urol Case Rep. 2018;18:18-20. doi:10.1016/j.eucr.2018.02.004

14. Riaz AA, Singh A, Brandt MT. Torsion of a testicular appendage. BMJ. 2014;348:g3051. doi:10.1136/bmj.g3051

15. Manohar CS, Keenan RJ, Donahoe FK, Yadav SP. The role of Prehn's sign in the diagnosis of testicular pain. Surgeon. 2008;6(2):88-90. doi:10.1016/s1479-666x(08)80069-2

16. Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC, Retik AB, Nguyen HT. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859-1864. doi:10.1016/j.juro.2012.10.056

17. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541. doi:10.1097/01.ccm.0000129486.35458.7d

18. Gilligan TD, Lin DW, Aggarwal R, Chism DD, Cost N, Derweesh IH, et al. Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019;17(12):1529-1554. doi:10.6004/jnccn.2019.0058

19. Mansbach JM, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12):1167-1171. doi:10.1001/archpedi.159.12.1167

20. Buckley JC, McAninch JW. Diagnosis and management of testicular rupture. Urol Clin North Am. 2006;33(1):111-116. doi:10.1016/j.ucl.2005.11.004

21. Arap MA, Vicentini FC, Cocuzza M, Hallak J, Athayde K, Lucon AM, Arap S. Late hormonal levels, semen parameters, and presence of antisperm antibodies in patients treated for testicular torsion. J Androl. 2007;28(4):528-532. doi:10.2164/jandrol.106.002097

22. Hocking JS, Geisler WM, Kong FYS. Update on the epidemiology, screening, and management of Chlamydia trachomatis infection. Infect Dis Clin North Am. 2023;37(2):267-288. doi:10.1016/j.idc.2023.02.007

23. Pinto KJ, Neville P, Nackman G, Moorthy CR, Noh PH. Testicular torsion: beyond salvage. J Urol. 2010;183(6):2399-2402. doi:10.1016/j.juro.2010.02.2380