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Referral and warning signs
When to refer
Urgent surgical referral (Urology) if Testicular Torsion cannot be excluded. Refer if: No clinical improvement within 72 hours of antibiotic therapy. Signs of scrotal abscess formation. Severe pain requiring parenteral analgesia/admission. Diagnostic uncertainty.
Red flags
- Sudden onset severe scrotal pain (suspect torsion)
- High-riding testis, horizontal lie
- Absent cremasteric reflex
- Signs of sepsis
- Failure to improve rapidly on antibiotics
Signs and symptoms
- Acute onset of unilateral scrotal pain
- Tenderness and swelling of the epididymis and/or testis
- Scrotal erythema (redness) and warmth
- May be associated with urethral discharge
- May have symptoms of urinary tract infection (dysuria, frequency)
- Fever, chills (less common)
Risk factors
- Sexually active men <35 years (Higher risk for STI causes - GC/Chlamydia)
- Men >35 years or recent urinary tract instrumentation (Higher risk for enteric organisms - E. coli, Pseudomonas)
- Unprotected sexual intercourse
- Multiple sexual partners
- Urinary tract abnormalities
- Heavy physical exertion (rarely)
- Mumps (viral orchitis)
Diagnosis
Clinical assessment
Based on history and physical examination finding of unilateral tender swelling of epididymis/testis. Check for urethral discharge. Prehn's sign (relief of pain with elevation of scrotum) may be positive but is unreliable. Crucially important to differentiate from testicular torsion.
Differential diagnosis
- Testicular Torsion (Surgical Emergency!) - Sudden severe pain, high-riding testis, absent cremasteric reflex, negative Prehn's sign.
- Torsion of testicular appendage
- Inguinal hernia (incarcerated/strangulated)
- Hydrocele, Spermatocele, Varicocele (usually painless)
- Testicular tumor (usually painless mass)
- Trauma / Hematoma
- Mumps orchitis
Investigations
- Urethral swab/First-void urine: Gram stain, Culture, NAAT for Gonorrhoea/Chlamydia (essential in sexually active men).
- Mid-stream urine (MSU): Microscopy, Culture & Sensitivity (especially in older men or if UTI symptoms).
- Scrotal Doppler Ultrasound: Essential if testicular torsion suspected (shows decreased/absent blood flow in torsion vs. increased flow in epididymo-orchitis). Can also detect abscess, hydrocele.
- Blood: CBC, STI screening (RPR/VDRL, HIV).
Diagnostic criteria
Clinical findings of epididymal/testicular tenderness and swelling, supported by investigations identifying likely pathogen (STI or urinary) or excluding torsion.
Management
Non-pharmacological management
- Bed rest
- Scrotal elevation/support (e.g., scrotal support underwear)
- Cold compresses/ice packs to scrotum
- Advise abstinence or condom use.
- Partner notification and treatment (if STI cause).
Pharmacological treatment
- Treat empirically based on likely cause (age/risk factors) while awaiting results:
- 1. Likely STI cause (Sexually active men <35 years OR positive GC/Chlamydia test):
- - Ceftriaxone 500 mg IM single dose (covers Gonorrhoea). UCG 2023 suggests 1g stat for urethral discharge persistence, consider higher dose here too.
- - PLUS Doxycycline 100 mg PO BID for 10-14 days (covers Chlamydia).
- 2. Likely Enteric Organism cause (Men >35 years, low STI risk, recent instrumentation, or confirmed UTI):
- - Ofloxacin 300 mg PO BID for 10-14 days OR Levofloxacin 500-750 mg PO once daily for 10-14 days.
- - Adjust based on urine culture results.
- 3. Analgesia: NSAIDs (e.g., Ibuprofen) are preferred for anti-inflammatory effect. Paracetamol.
- 4. Treat sexual partners according to findings (if STI).
Monitoring
Monitor for clinical improvement within 48-72 hours. Follow up to ensure resolution.
Complications
- Scrotal abscess
- Testicular infarction/atrophy
- Infertility (bilateral involvement)
- Chronic epididymitis/orchalgia (persistent pain)
- Sepsis (rare)
Prevention
- Consistent and correct condom use
- Prompt treatment of urethritis/UTIs
- Mumps vaccination
Patient education
- Explain the diagnosis, differentiating from torsion if possible.
- Stress importance of completing antibiotics.
- Advise on supportive measures (rest, scrotal support, ice).
- Explain need for partner treatment if STI.
- Advise return if pain worsens or fails to improve in 2-3 days.
- Discuss prevention.
Uganda-specific notes
Differentiating from testicular torsion is paramount and requires high index of suspicion; refer urgently if uncertain. STI pathogens common in younger men. Follow UCG protocol for urethral discharge if present.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2.8.2
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2.1 (for urethral discharge component)