22yo male presents to emergency department with a 2-hour history of increasingly intense testicular pain.  He reports being sexually active with multiple partners and intermittent condom use.  He is a very active person and completed a triathlon the day before presentation.  He denies dysuria, urethral discharge, or flank pain, but did have an episode of vomiting prior to arrival.  He is in visible distress and can not seem to get comfortable.  Evaluation of the scrotum reveals a tender, swollen left testicle.

1. What are some bedside maneuvers you can perform to help with the differential?
   1. Epididymitis
      1. Point tenderness over the superior aspect of the testicle
      2. (+) Prehn Sign
         1. Manual elevation of the testicle improves pain
   2. Testicular Torsion
      1. High-riding and/or horizontal lie of testicle (“Bell Clapper Deformity)
      2. 
      3. Absent cremesteric reflex
         1. Normal = pinching/stroking the thigh causes ipsilateral elevation of testicle
      4. (-) Prehn Sign
   3. Torsion of Appendix Testes
      1. More common in children
      2. 
      3. (+) Blue Dot Sign
      4. 

1. What should be the initial management of this patient?
   1. If suspected epididymitis:
      1. Urinalysis, urine culture, and gonorrhea/chlamydia testing
      2. Antibiotics are directed towards:
         1. C. trachomatis or N. gonorrhoeae
            1. Ceftriaxone 250mg IM and doxycycline 100mg PO BID x 10 days
         2. Gram-negative enteric pathogens
            1. Levofloxacin 500mg PO daily x 10 days
   2. If suspected testicular torsion:
      1. Manual detorsion may be attempted
         1. 2/3 torse medially and detorsion is performed by rotating testicle outwards laterally
      2. Ultrasound may be performed if immediately available (this should not delay surgical consult or evaluation)
         1.  

         2.  

      3.  Surgical evaluation and management is the preferred initial management of patients with suspected testicular torsion
   3. If suspected torsion of appendix testes:
      1. Ultrasound is performed to rule-out other pathologies.
      2. Management is conservative with rest, ice, and NSAIDs.
      3. Surgical removal may be required if pain does not improve with conservative management.

References

1. Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. The Urologic Clinics of North America. 35(1):101-8; vii. 2008. [pubmed]
2. Galejs LE. Diagnosis and treatment of the acute scrotum. American Family Physician. 59(4):817-24. 1999. [pubmed]
3. Workowski KA, Bolan GA, . Sexually transmitted diseases treatment guidelines, 2015. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64(RR-03):1-137. 2015. [pubmed]
4. Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA. Testicular torsion: direction, degree, duration and disinformation. The Journal of Urology. 169(2):663-5. 2003. [pubmed]
5. Palestro CJ, Manor EP, Kim CK, Goldsmith SJ. Torsion of a testicular appendage in an adult male. Clinical Nuclear Medicine. 15(7):515-6. 1990. [pubmed]