reveals normal or increased blood flow to the testis, and may demonstrate a low echogenicity structure with a central hypoechogenic area Diagnostically, a surgical exploration may be required to be certain that torsion of the testis is not present The treatment of a torsed testicular or epididymal appendage is supportive with rest, support of the scrotum, and analgesic/anti-inflammatory medications The pain usually resolves in to 10 days Rarely, removal of the torsed appendage occurs when there is severe or prolonged pain Contralateral scrotal exploration is not indicated Epididymitis/Orchitis Epididymitis is an infection or inflammation of the epididymis which occurs more frequently in sexually active adolescents and adults In sexually active adolescents, it is most commonly associated with Chlamydia trachomatis, but Neisseria gonorrhea, Escherichia coli, Mycobacterium, and viruses are other important etiologies In HIV-infected males, Mycobacterium, cytomegalovirus, and Cryptococcus must also be considered Less frequently, epididymitis does occur in prepubertal and nonsexually active adolescent boys, primarily associated with Mycoplasma pneumoniae, enterovirus, and adenovirus infections Bacterial epididymitis is uncommon, but related to urinary tract infections with coliform organisms caused by structural abnormalities of the urinary tract The onset of swelling and pain is typically more gradual than with torsion of the testis or a testicular appendage, but can be abrupt in onset Associated symptoms of urinary frequency, dysuria, penile discharge, or fever may be present Scrotal edema and erythema are often present The testicle should have a normal lie and the cremasteric reflexes should be intact Early on, the epididymis may be selectively enlarged and tender, readily distinguished from the testis With time, inflammation spreads to the testis (orchitis) and surrounding scrotal wall, making localization difficult Although elevation of the scrotum may relieve pain in epididymo-orchitis (Prehn sign) it is not considered as reliable Although pyuria is seen more often in epididymitis than in torsion, it is not consistently present The urinalysis can be normal, and urine cultures are often negative in epididymitis, but are still recommended The Centers for Disease Control and Prevention recommends a Gram stain and culture of urethral discharge or intraurethral swab, or nucleic acid amplification tests for N gonorrhea and C trachomatis which can be done on urine or an intraurethral swab, and a urinalysis and culture Color Doppler sonography typically demonstrates an increase in size and blood flow to the testis and epididymis ( Fig 61.6 )