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Acute testicular pain represents about 0.5% of ED complaints.1 Causes of acute testicular pain include trauma, epididymitis, orchitis, torsion of the testicular appendage, and hernia; however, testicular torsion is the diagnosis of the greatest concern in the emergency setting.

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The traditional teaching was that most patients presenting to an ED or urgent care with a complaint of acute testicular pain had testicular torsion.2 This misconception has been dispelled and it is now known that the most common etiology of acute testicular pain is epididymitis.2 However, the evaluation of acute testicular pain presents a considerable challenge for emergency providers, since 50% of patients presenting with testicular torsion have delayed seeking care for >6 hours and are at high risk of losing the torsed testicle.3

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The issue of acute testicular pain is further complicated by the high potential for litigation associated with infertility after testicular loss due to torsion or disruption of the testicle from severe trauma. When the diagnosis of testicular torsion is missed, the majority of patients have been incorrectly diagnosed with epididymitis.4

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High-resolution color Doppler ultrasonography has become widely accepted as the test of choice for evaluating acute scrotal pain, replacing scintigraphy in most institutions.5 While scintigraphy requires less technical skill on the part of the radiologist consulted to evaluate the patient, there are major drawbacks to the technique. Scintigraphy is a time-consuming process that can add an hour or more to the evaluation of a patient who may already be several hours into the testicular torsion process.5 Furthermore, the resultant hyperemia of the scrotal skin during testicular torsion can mask a lack of blood flow to the testicle itself and lead to a misdiagnosis in less experienced hands.6 This nuclear medicine study also provides no information regarding testicular anatomy, which is a critical issue if pathology other than torsion is present. MRI is a promising imaging modality for detecting acute scrotal problems, including ischemia caused by torsion. However, MRI is expensive and time consuming.

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Traditionally the history and physical examination were thought to be the keys to diagnosing or ruling out testicular torsion.3 However, the historical features of several disease processes may be similar. For example, the duration of pain in testicular torsion, epididymitis, orchitis, and torsion of a testicular appendage frequently overlap.7 Also, only 50% of patients with torsion have sudden onset of pain and about 20% of have pain associated with trauma or physical exertion, such as heavy lifting.8,9 Adding to the difficulty using the history is the fact that many young men do not provide an accurate history of trauma. The physical exam can be similarly misleading, because it is frequently limited by pain, edema, and patient compliance. In addition, findings such as absent cremasteric reflex, abnormal testicular lie (present in <50% of testicular torsion cases), and epididymal tenderness are not reliable in differentiating torsion from other causes of acute scrotal pain.10

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The classic clinical features of epididymitis, such as dysuria and urethral discharge, ...

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