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©2013 UpToDate ® Print Email The acute scrotum: suggested disposition and treatment Testicular torsion Indications for surgery: Suggestive history or physical examination Similar episodes >2 weeks ago No flow or spermatic cord knot by Doppler ultrasound Diagnostic uncertaintyΔ Treatment: Definitive: surgery Temporizing: trial of manual detorsion Torsion of appendage Admission criteria: Testicular torsion excluded Severe pain Pain refractory to trial of analgesics and conservative management Treatment: Analgesics Rest Acute epididymitis Admission criteria: Testicular torsion excluded Severe pain Immunocompromised Not tolerating oral medications or noncompliant Treatment: Children: If pyuria >3 WBC/hpf or positive culture, or if underlying GU abnormality: Antibiotic course against coliforms* If no pyuria and negative culture: Antibiotics not required Extensive evaluation not required Sexually active adolescents: Heterosexual: empiric antibiotics (chlamydia, GC)• Homosexual: empiric antibiotics (chlamydia, GC and coliforms)• * Antibiotic choices include: Trimethoprim (TMP)-sulfamethoxazole (6-12 mg TMP component/kg per day divided every 12 hours) or cephalexin (25-50 mg/kg per day divided every 6-8 hours). • Ceftriaxone (250 mg IM in one dose) plus doxycycline (100 mg PO twice a day for 10 days). Ofloxacin (300 mg PO twice a day for 10 days) or levofloxacin (500 mg PO once daily for 10 days) is recommended for adolescents in whom enteric organisms (coliforms) are most likely or in whom gonococcal culture or nucleic acid amplification test is negative. ΔSignificant overlap in clinical fndings and diagnostic studies may occur for testicular torsion, torsed appendage, or acute epididymitis. Exploratory surgery may ultimately be necessary to determine the etiology of scrotal pain. Adapted with permission from: Burgher, SW. Acute scrotal pain. Emerg Med Clin North Am 1998; 16:781. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR Recomm Rep 2006; 55:1. Updated recommended treatment guidelines for gonococcal infections and associated treatment conditions - United States, April 2007. Available at: www.cdc.gov/std/treatment/2006/GonUpdateApril2007.pdf.