Acute Scrotum Evaluation and Management

Clinical Assessment and Diagnosis

The American Urological Association recommends immediate evaluation with scrotal ultrasound with Doppler to differentiate between testicular torsion, testicular rupture, testicular tumor, and epididymitis/epididymo-orchitis in patients with a hard tender testicle 1
Abrupt onset of severe scrotal pain suggests testicular torsion, while gradual onset suggests epididymitis, with testicular torsion having a bimodal distribution in neonates and postpubertal boys, and epididymitis being most common in adults over 25 years 1
Pain that is NOT relieved with testicular elevation (negative Prehn sign) suggests torsion 1
Scrotal ecchymosis, swelling, or difficulty identifying testicular contours suggests testicular rupture 2
Urinary symptoms such as blood at urethral meatus, gross hematuria, or inability to void may indicate concomitant urethral injury 2
A tender nodule with blue discoloration on the upper pole suggests torsion of testicular appendage, most common in prepubertal boys 1
Marked scrotal wall thickening with minimal pain may suggest acute idiopathic scrotal edema 1

Urinalysis should be obtained to evaluate for urinary tract infection or urethritis, though normal urinalysis does NOT exclude testicular torsion 1
Gram stain of urethral exudate should be evaluated for >5 polymorphonuclear leukocytes per oil immersion field if epididymitis is suspected 4
Serum tumor markers such as β-HCG, AFP, and LDH should be obtained before any intervention if testicular mass is suspected 3
Duplex Doppler ultrasound of the scrotum is the first-line imaging modality and should include grayscale examination, color Doppler assessment, power Doppler, and spectral Doppler analysis 1

The American College of Emergency Physicians recommends immediate urological consultation and surgical exploration with detorsion for testicular torsion, with bilateral orchiopexy to prevent recurrence 1, 2
Scrotal exploration and debridement with tunical closure or orchiectomy is recommended for testicular rupture 2
Empiric antibiotic therapy based on age and risk factors is recommended for epididymitis, with ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 10 days for patients under 35 years or sexually active 4
Inguinal orchiectomy is the primary treatment for testicular tumor, with sperm banking discussion before any therapeutic intervention 1, 3