Acute Scrotum: Evaluation and Management

Clinical Presentation and Diagnosis

The American Urological Association recommends that right testicular pain be treated as testicular torsion until proven otherwise, requiring immediate urological consultation and surgical exploration within 6-8 hours of symptom onset to prevent permanent testicular loss 1
Sudden, severe onset of testicular pain with nausea and vomiting strongly suggests testicular torsion, which presents with a high-riding testicle, absent cremasteric reflex, and negative Prehn sign (pain NOT relieved by elevation) 1
Gradual onset of testicular pain over hours to days suggests epididymitis, which may have fever, dysuria, or urethral discharge, and is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae in men under 35 years 2
In men over 35 years, epididymitis is usually caused by gram-negative enteric organisms from urinary tract infections or instrumentation 2

Urgent Duplex Doppler ultrasound is indicated in cases of intermediate clinical suspicion, with grayscale findings to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) and color Doppler assessment showing decreased or absent testicular blood flow (96-100% sensitivity) 1
Power Doppler is particularly useful in prepubertal patients with normally low flow, and comparison to the contralateral testicle as an internal control is recommended 1

The Centers for Disease Control and Prevention recommends empiric antibiotic therapy for confirmed epididymitis, based on age and risk factors, with coverage for C. trachomatis and N. gonorrhoeae in men under 35 years, and gram-negative enteric organisms in men over 35 years 2
Hospitalization is indicated for severe pain, fever, or concern for abscess, and supportive care includes bed rest, scrotal elevation, and analgesics 2
Diagnostic workup for epididymitis includes gram stain of urethral exudate, nucleic acid amplification test for N. gonorrhoeae and C. trachomatis, urinalysis, and urine culture, as well as syphilis serology and HIV testing 1, 2