Scrotal Emergencies in the ED: Torsion, Trauma, and Epididymitis 

Introduction

Scrotal complaints in the ED can be awkward, confusing, and devastating if missed. While many causes are benign, three specific entities demand immediate recognition and decisive action: testicular torsion, epididymitis, and scrotal trauma. With slow recognition and action, you can be looking at testicular infarction, missed infections, or irreversible damage from blunt or penetrating injury.

This guide is your crash course in navigating the high-stakes, high-anxiety world of acute scrotal pathology in the emergency department. Let’s dive in!

Testicular Torsion: Time Is Tissue

Let’s start with a classic: testicular torsion. The pathophysiology is straightforward; twisting of the spermatic cord compromises blood flow to the testes, rapidly leading to ischemia. The majority of cases occur in males between 12 and 18 years old, often thanks to the “bell-clapper” deformity that allows testicles to rotate freely within the tunica vaginalis. Not so fun fact: up to 42% of torsed testes are non-viable at the time of surgery if not addressed early (first 12 hours after torsion event).^1,2

This truly is a “must-not-miss” diagnosis; patients will often present with sudden, severe, unilateral testicular pain, often waking them from sleep. For this pathology, think pain with nausea and vomiting, not really with dysuria or fever. You may see board questions stating the testicle is “high riding and lying horizontally”, however the most classic clue on boards is the absence of the cremasteric reflex. You stroke the inner thigh and… nothing – that’s a bad sign. 

Ultrasound with color doppler can be helpful, but testicular torsion is technically a clinical diagnosis. Ultrasound will often show an enlarged, hypoechoic testicle with absent or decreased flow, but again, surgery should not be delayed for imaging if you’re already convinced.³ Don’t wait around if the story screams torsion! These patients will be very uncomfortable, and an absent cremasteric reflex in this context is more than enough reason to call our surgery friends.

If you’re in a resource-limited setting or stuck waiting, attempt manual detorsion. Often referred to as “opening a book”, rotate the testicle outward (medial to lateral) in 180° increments. If the patient reports significant relief, you might’ve bought some time, but even with success, patients still need operative fixation.

Factors affecting outcomes generally include time to salvage in the OR, age of the patient, and use of ultrasound for diagnosis, with these criteria all indirectly related to rates of testicular viability.⁴

Epididymitis: The Sneaky Twin

Epididymitis can present similarly to torsion but classically has a very different tempo. Think gradual onset of pain over days rather than rapid pain over hours. In these cases, the epididymis becomes inflamed due to retrograde spread of bacteria through the vas deferens. Etiology often depends on age:

●     <35 years: classically secondary to STIs (chlamydia and gonorrhea)

●     >35 years: classically secondary to coliform bacteria (e.g., E. coli), often due to underlying urinary tract issues ^5,6

This pain is typically accompanied by dysuria, frequency, and/or fever. Unlike torsion, our cremasteric reflex is intact! The Prehn sign (pain relief with scrotal elevation) might be positive, but don’t rely on that; the Prehn sign was taught in medical school and still mentioned on boards, but it is very inaccurate in clinical practice. On ultrasound, you may see increased blood flow to the epididymis (hyperemia with doppler), possibly with an enlarged or hypoechoic structure abutting the epididymitis. And unlike torsion, blood flow to the testes is preserved or even increased.⁷

Treatment? That depends on clinical practice vs boards. For your board exam, treatment is based on age:

●     <35 years: Cover for STIs (think ceftriaxone + doxycycline)

●     >35 years or in patients with GU abnormalities: Cover for coliforms (10 days of levofloxacin or trimethoprim/sulfamethoxazole will do the trick!)

In clinical practice, we all know that just because some patients are over 35 years old, doesn’t mean they can’t have an STI. Do a diligent history; if ever a time to ask about sexual history, this is it! If you have any suspicion for STI, trust your gut and treat appropriately. 

Adjuncts for pain control include scrotal support, NSAIDs, and patient education on the typical time course to recovery (7-10 days). No need to call urology unless there’s a suspected abscess, systemic illness, or if the patient has failed outpatient treatment.

Scrotal Trauma: Broken Balls

Unlike the sneaky presentation of torsion and epididymitis, trauma is usually obvious. Our concern here isn’t subtle pain, dysuria, or subacute symptoms. Instead, we worry about testicular rupture, hematocele, or torsion secondary to trauma (yes, it can happen). These patients may present after blunt trauma (such as sports injuries, handlebar accidents, or MVCs) or penetrating trauma (think animal bites, stab wounds, etc.).

A physical exam can be challenging due to swelling and pain, but any loss of testicular contour, large hematoceles on secondary survey, or discoloration/ecchymosis of the scrotum should raise alarm bells.⁸ Concern for a pelvic injury does not change our trauma primary and secondary survey – just remember to fully undress your patient and evaluate the perineum to assess for these injuries! Ultrasound is once again our MVP. Look for:¹⁴

●     Disruption of the tunica albuginea

●     Heterogeneous echotexture of the testes

●     Absence of blood flow (suggests infarction/torsion)

Management depends on our findings:^10-13

●     Minor contusions can be managed with ice, rest, NSAIDs, and testicular elevation

●     Large hematoceles or suspected rupture are met with surgical exploration (get urology involved early!)

●     Penetrating trauma: don’t wait – this is a direct ticket to the OR!

Prompt imaging and surgical consultation can make the difference between preservation and orchiectomy.

Conclusion

Scrotal emergencies require a rapid, focused assessment and decisive action. Among the spectrum of causes, testicular torsion stands out as the most time-sensitive if missed. The ability to distinguish these three pathologies from one another is essential for any emergency clinician. When torsion is suspected, do not let imaging delay surgical consultation or intervention – time directly correlates with testicular salvageability. Epididymitis, while more common and typically less emergent, still warrants thoughtful evaluation and pathogen-specific antibiotic treatment. Trauma to the scrotum, though usually obvious, should not be underestimated; prompt recognition of rupture or vascular compromise is key to preserving testicular function.

In short, any complaint involving acute scrotal pain should immediately prompt a structured evaluation. Prioritize torsion, tailor treatment for infections, and escalate trauma cases appropriately. A high index of suspicion, coupled with timely intervention, can make the difference between a recovered testicle and a missed opportunity for salvage. Proper evaluation and management in these cases effectively protect long-term function, fertility, and quality of life.

References

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