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Scrotal Pain

by Anuja P. Shah, MD

Scrotal pain can occur in males of any age, from neonates to the elderly.

Etiology

The most common causes of scrotal pain include

  • Testicular torsion

  • Torsion of the testicular appendage

  • Epididymitis

There are a number of less common causes (see Table: Some Causes of Scrotal Pain). Age, onset of symptoms, and other findings can help determine the cause.

Some Causes of Scrotal Pain

Cause

Suggestive Findings

Diagnostic Approach

Testicular torsion

Sudden onset of severe, unilateral, constant pain

Cremasteric reflex absent

Asymmetric, transversely oriented, high-riding testis on affected side

Typically occurring in neonates and postpubertal boys but can occur in adults

Color Doppler ultrasonography

Appendiceal torsion (a vesicular nonpedunculated structure attached to the cephalic pole of the testis)

Subacute onset of pain over several days

Pain in the upper pole of testis

Cremasteric reflex present

Possibly reactive hydrocele, blue dot sign (blue or black spot under the skin on superior aspect of testis or epididymis)

Typically occurs in boys aged 7–14 yr

Color Doppler ultrasonography

Epididymitis or epididymo-orchitis, usually infectious, with gram-negative organisms in prepubertal boys and older men or, in sexually active men, sexually transmitted disease

Can be noninfectious, resulting from urine reflux into ejaculatory ducts

Acute or subacute onset of pain in the epididymis and sometimes also the testis

Possibly urinary frequency, dysuria, recent lifting or straining

Cremasteric reflex present

Often scrotal induration, swelling, erythema

Sometimes penile discharge

Typically occurring in postpubertal boys and men

Urinalysis and culture

Nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis

Postvasectomy, acute and chronic (postvasectomy pain syndrome)

History of vasectomy

Pain during intercourse, ejaculation, or both

Pain during physical exertion

Tender or full epididymis

Clinical evaluation

Trauma

Clear history of trauma to the genitals

Often swelling, possible intratesticular hematoma or hematocele

Color Doppler ultrasonography

Inguinal hernia (strangulated)

Long history of painless swelling (often known diagnosis of hernia) with acute or subacute pain

Scrotal mass, usually large, compressible, possibly with audible bowel sounds

Not reducible

Clinical evaluation

Immunoglobulin A–associated vasculitis (Henoch-Schönlein purpura)

Palpable purpura (typically of lower extremities and buttocks), arthralgia, arthritis, abdominal pain, renal disease

Typically occurring in boys aged 3–15 yr

Clinical evaluation

Sometimes biopsy of skin lesions

Polyarteritis nodosa

Fever, weight loss, abdominal pain, hypertension, edema

Skin lesions including palpable purpura and subcutaneous nodules

Can be acute or chronic

May cause testicular ischemia and infarction

Most common in men aged 40–50 yr

Angiography

Sometimes biopsy of affected organ

Referred pain (abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, postherniorrhaphy pain)

Normal scrotal examination

Sometimes abdominal tenderness depending on cause

Directed by examination findings and suspected cause

Orchitis (usually viral—eg, mumps; rubella; coxsackievirus, echovirus, or parvovirus infection)

Scrotal and abdominal pain, nausea, fever

Unilateral or bilateral swelling, erythema of scrotum

Acute and convalescent viral titers

Fournier gangrene (necrotizing fasciitis of the perineum)

Severe pain, fever, toxic appearance, erythema, blistering or necrotic lesions

Sometimes palpable subcutaneous gas

Sometimes history of recent abdominal surgery

More common in older men with diabetes, peripheral vascular disease, or both

Clinical evaluation

Evaluation

Expeditious evaluation, diagnosis, and treatment are required because untreated testicular torsion may cause loss of a testis.

History

History of present illness should determine location (unilateral or bilateral), onset (acute or subacute), and duration of pain. Important associated symptoms include fever, dysuria, penile discharge, and presence of scrotal mass. Patients should be asked about preceding events, including injury, straining or lifting, and sexual contact.

Review of systems should seek symptoms of causative disorders, including purpuric rash, abdominal pain, and arthralgias (immunoglobulin A–associated vasculitis [Henoch-Schönlein purpura]); intermittent scrotal masses, groin swelling, or both (inguinal hernia); fever and parotid gland swelling (mumps orchitis); and flank pain or hematuria (renal calculus).

Past medical history should identify known disorders that may cause referred pain, including hernias, abdominal aortic aneurysm, renal calculi, and risk factors for serious disorders, including diabetes and peripheral vascular disease (Fournier gangrene).


Physical examination

Physical examination begins with a review of vital signs and assessment of the severity of pain. Examination focuses on the abdomen, inguinal region, and genitals.

The abdomen is examined for tenderness and masses (including bladder distention). Flanks are percussed for costovertebral angle tenderness.

Inguinal and genital examination should be done with the patient standing. Inguinal area is inspected and palpated for adenopathy, swelling, or erythema. Examination of the penis should note ulcerations, urethral discharge, and piercings and tattoos (sources of bacterial infections). Scrotal examination should note asymmetry, swelling, erythema or discoloration, and positioning of the testes (horizontal vs vertical, high vs low). Cremasteric reflex should be tested bilaterally. The testes, epididymides, and spermatic cords should be palpated for swelling and tenderness. If swelling is present, the area should be transilluminated to help determine whether the swelling is cystic or solid.


Red flags

The following findings are of particular concern:

  • Sudden onset of pain; exquisite tenderness; and a high-riding, horizontally displaced testis (testicular torsion)

  • Inguinal or scrotal nonreducible mass with severe pain, vomiting, and constipation (incarcerated hernia)

  • Scrotal or perineal erythema, necrotic or blistered skin lesions, and toxic appearance (Fournier gangrene)

  • Sudden onset of pain, hypotension, weak pulse, pallor, dizziness, and confusion (ruptured abdominal aortic aneurysm)


Interpretation of findings

The focus is to distinguish causes that require immediate treatment from others. Clinical findings provide important clues (see Table: Some Causes of Scrotal Pain).

Aortic catastrophes and Fournier gangrene occur primarily in patients > 50 yr; the other conditions that require immediate treatment can occur at any age. However, testicular torsion is most common in neonates and postpubertal boys, torsion of the testicular appendage occurs most commonly in prepubertal boys (7 to 14 yr), and epididymitis is most common in adolescents and adults.

Severe, sudden onset of pain suggests testicular torsion or renal calculus. Pain from epididymitis, incarcerated hernia, or appendicitis is of more gradual onset. Patients with torsion of the testicular appendage present with moderate pain that develops over a few days; pain is localized to the upper pole. Bilateral pain suggests infection (eg, orchitis, particularly if accompanied by fever and viral symptoms) or a referred cause. Flank pain that radiates to the scrotum suggests renal calculus or, in men > 55 yr, abdominal aortic aneurysm.

Normal findings on scrotal and perineal examination suggest referred pain. Attention must then be directed to extrascrotal disorders, particularly appendicitis, renal calculi, and, in men > 55, abdominal aortic aneurysm.

Abnormal scrotal and perineal examination findings often suggest a cause. Sometimes, early in epididymitis, tenderness and induration may be localized to the epididymis; early in torsion, the testis may be clearly high-riding, with a horizontal lie and the epididymis not particularly tender. However, frequently the testis and epididymis are both swollen and tender, there is scrotal edema, and it is not possible to differentiate epididymitis from torsion by palpation. However, the cremasteric reflex is absent in torsion, as are findings of a sexually transmitted disease (STD—eg, purulent urethral discharge); the presence of both of these findings makes epididymitis quite likely.

Sometimes, a scrotal mass caused by a hernia may be palpable in the inguinal canal; in other cases, hernia can be difficult to distinguish from testicular swelling.

Painful erythema of the scrotum with no tenderness of the testes or epididymides should raise suspicion of infection, either cellulitis or early Fournier gangrene.

A vasculitic rash, abdominal pain, and arthralgias are consistent with a systemic vasculitis syndrome such as immunoglobulin A–associated vasculitis or polyarteritis nodosa.


Testing

Testing is typically done.

  • Urinalysis and culture (all patients)

  • STD testing (all patients with positive urinalysis, discharge, or dysuria)

  • Color Doppler ultrasonography to rule out torsion (no clear-cut alternate cause)

  • Other testing as suggested by findings (see Some Causes of Scrotal Pain)

Urinalysis and culture are always required. Findings of UTI (eg, pyuria, bacteriuria) suggest epididymitis. Patients with findings that suggest UTI and patients with urethral discharge or dysuria should be tested for STDs as well as other bacterial causes of UTI.

Timely diagnosis of testicular torsion is critical. If findings are highly suggestive of torsion, immediate surgical exploration is done in preference to testing. If findings are equivocal and there is no clear alternate cause of acute scrotal pain, color Doppler ultrasonography is done. If Doppler ultrasonography is not available, radionuclide scanning may be used but is less sensitive and specific.


Treatment

Treatment is directed at the cause and can range from emergency surgery (testicular torsion) to bed rest (torsion of the testicular appendage). If testicular torsion is present, prompt surgery (< 12 h after presentation) is generally required. Delayed surgery may lead to testicular infarction, long-term testicular damage, or the loss of a testis. Surgical detorsion of the testis relieves the pain immediately, and simultaneous bilateral orchiopexy prevents recurrence of torsion.

Analgesics, such as morphine or other opioids, are indicated for the relief of acute pain. Antibiotics are indicated for cases of bacterial epididymitis or orchitis.

Geriatrics Essentials

Testicular torsion is uncommon in elderly men, and when present, the manifestations are usually atypical and therefore diagnosis is delayed. Epididymitis, orchitis, and trauma are more common in elderly men. Occasionally, inguinal hernia, colon perforation, or renal colic may cause scrotal pain in elderly men.

Key Points

  • Always consider testicular torsion in patients with acute scrotal pain, particularly in children and adolescents; quick, accurate diagnosis is essential.

  • Other common causes of scrotal pain are torsion of the testicular appendage and epididymitis.

  • Color Doppler ultrasonography is usually done when the diagnosis is unclear.

  • Normal findings on scrotal and perineal examination suggest referred pain.

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