How should I approach the investigation of a patient presenting with testicular pain and swelling?

Approach to investigation of a patient presenting with testicular pain and swelling:

• If testicular torsion is suspected clinically (sudden onset severe pain), arrange emergency hospital admission for immediate surgical exploration ideally within 4 hours to preserve testicular viability and fertility.
• If there is a history of previous episodes of severe, self-limiting scrotal pain or swelling, arrange a urology referral to investigate possible spontaneous torsion and detorsion.
• If testicular cancer is suspected on examination or incidentally on ultrasound (e.g., painless testicular enlargement or mass), arrange an urgent 2-week suspected cancer pathway referral to urology and consider blood tests for tumour markers (AFP, hCG, LDH) as per local guidelines.
• If haematocele is suspected following acute trauma, arrange emergency hospital admission; if atraumatic or chronic, arrange urgent scrotal ultrasound and onward urology referral.
• Use Doppler ultrasound to assess testicular perfusion and to help differentiate causes such as torsion, epididymo-orchitis, or trauma-related injury.
• If epididymal cyst is diagnosed and asymptomatic, reassure the patient; if symptomatic, consider routine urology referral.

Summary: Immediate hospital admission is critical if torsion is suspected. Urgent urology referral is needed for suspected cancer or recurrent severe pain episodes. Ultrasound imaging and tumour markers guide further management. Trauma-related swelling requires urgent assessment to exclude rupture or haematocele. Symptomatic cysts may need specialist input ¹.