The diagnosis should generally be made based on the presenting symptoms. An ultrasound can be useful when the diagnosis is unclear. However, imaging should not delay surgical intervention as complications develop with prolonged ischemia. Immediate surgery is recommended regardless of imaging findings if there is a high degree of suspicion based on history and physical examination. Given the treatment implications of<unk> , it is important to distinguish<unk>  from other causes of<unk>  pain, such as epididymitis, which can present similarly. While both conditions can cause<unk>  pain, the pain of epididymitis is typically localized to the epididymis at the rear pole of the testicle. Epididymitis may also be characterized by discoloration and swelling of the testis, and fever. The cremasteric reflex in epididymitis is usually present.<unk> , or more probably impending<unk>  infarction, can also produce a low-grade fever. There is often an absent or decreased cremasteric reflex. Clinical exam The absence of the cremasteric reflex in an acutely painful testicle is most indicative of<unk>  (the twisting of the spermatic cord of the testicle makes reflexive responses all but impossible). The cremasteric reflex normally causes elevation of the testicle by stroking the inner thigh. Absence is especially common in children, but its presence does not exclude a diagnosis of<unk> . On physical examination, the testis can be swollen, tender, high-riding, and with an abnormal transverse lie. Prehn's sign, a classic physical exam finding, has not been reliable in distinguishing torsion from other causes of<unk>  pain such as epididymitis. The individual will not usually have a fever, though nausea is common. Imaging A doppler ultrasound scan of the scrotum can identify the absence of blood flow in the twisted testicle and is nearly 90% accurate in diagnosis. It can also help distinguish torsion from epididymitis. Radionuclide scanning (scintigraphy) of the scrotum is the most accurate imaging technique, but it is not routinely available, particularly with the urgency that might be required. The agent of choice for this purpose is technetium-99m pertechnetate. Initially it provides a radionuclide angiogram, followed by a static image after the radionuclide has perfused the tissue. In the healthy patient, initial images show symmetric flow to the testes, and delayed images show uniformly symmetric activity. In<unk> , the images may show heterogenous activity within the affected testicle.
Testicular torsion
Epididymitis
Inguinal hernia
Hydrocele testis
Appendix of testis
Testicular rupture
Ovarian torsion
Penile fracture