Differential Diagnosis and Management of Testicular Pain with Urinary Symptoms

Clinical Presentation and Diagnosis

The clinical presentation of gradual onset over 2 weeks, bilateral involvement, urinary frequency, and pain with ejaculation most strongly suggests epididymitis 1
Gradual onset of pain over days to weeks is the hallmark distinguishing feature from testicular torsion 1
Urinary frequency and dysuria commonly accompany epididymitis 2
Pain with ejaculation is characteristic of epididymo-orchitis 2
Bilateral involvement can occur, though unilateral is more common 1
May have abnormal urinalysis, though normal urinalysis does not exclude the diagnosis 1
Pain in the perineum, suprapubic region, testicles, or tip of penis that is exacerbated by urination or ejaculation is characteristic of chronic prostatitis/chronic pelvic pain syndrome 2
Voiding symptoms including urinary frequency and sense of incomplete bladder emptying are common in chronic prostatitis/chronic pelvic pain syndrome 2

Urinalysis and urine culture are essential to evaluate for infection 1
Duplex Doppler ultrasound is necessary if any concern for torsion or to confirm epididymitis 1
Epididymal tenderness and swelling are important physical examination findings to assess 1
Prehn sign (pain relief with testicular elevation) suggests epididymitis 1
Cremasteric reflex (absent in torsion, present in epididymitis) is an important physical examination finding 1
Urgent Doppler ultrasound is indicated if pain becomes sudden or severe 1
Any concern for torsion exists, as false-negative Doppler can occur with partial torsion or spontaneous detorsion 1

Empiric antibiotic therapy should be initiated immediately while awaiting culture results for epididymitis 1
Scrotal elevation and support are recommended as supportive measures 1
NSAIDs for pain control are recommended as supportive measures 1
Bed rest until inflammation subsides is recommended as a supportive measure 1
Alpha-blockers and anti-inflammatory agents may provide benefit for chronic prostatitis/chronic pelvic pain syndrome 2

Reassess for symptom improvement within 48-72 hours, and reconsider torsion or other diagnoses if pain worsens or fails to improve 1
Normal urinalysis does not exclude either epididymitis or testicular torsion 1
Significant overlap exists in clinical presentation between different causes of scrotal pain, and a high index of suspicion should be maintained 1
Do not delay imaging if any clinical suspicion for torsion exists, as testicular viability is compromised after 6-8 hours 1