Chapter 31 · Acute lower urinary tract conditions
Torsion of the appendix testis, epididymitis, and orchitis
Torsion of the appendix testis
Features:
- More common in adolescents.
- Pain is less severe than in testicular torsion.
- The “blue dot” sign (a bluish lesion at the upper pole of the testis).
- Preserved blood flow on ultrasonography.
- Conservative treatment: anti-inflammatory medication, cold application, rest.
Epididymitis and orchitis
Causes: infection (UTI, STI), trauma, congestion.
Clinical presentation:
- Gradual onset.
- Scrotal pain, swelling, and redness.
- Fever, dysuria.
- Pain relief on elevation of the testis is not sufficiently accurate to exclude torsion and must not be used as the decisive test.
Diagnosis:
- Doppler ultrasonography (increased blood flow).
- Urinalysis, culture, STI screening.
Treatment:
- Select the antibiotic according to the likely etiology: gonorrhea or chlamydia, mixed STI and enteric flora risk, or enterobacteria after instrumentation. Perform NAAT or PCR and urine culture as indicated.
- Anti-inflammatory medication, cold application, rest.
- Drain an abscess.
Algorithm
| Step | Action |
|---|---|
| 1 | Rule out testicular torsion first; Prehn's sign is not decisive |
| 2 | Doppler ultrasonography for uncertainty, without delaying exploration |
| 3 | Torsion of the appendix testis: conservative treatment |
| 4 | Epididymitis: assess the risk of STI, mixed infection, or enterobacterial infection |
| 5 | NAAT or PCR and culture; etiology-directed therapy according to the local protocol; drain an abscess |
Cross-references: Chapters 29–31 and 42.