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 Scrotal Pain: A Merck Manual of Patient Symptoms podcast
Scrotal pain can occur in males of any age, from neonates to the elderly.
Etiology
The most common causes of scrotal pain include
There are a number of less common causes (see Table 7: Symptoms of Genitourinary Disorders: Some Causes of Scrotal Pain ). Age, onset of symptoms, and other findings can help determine the cause.
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Table 7
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| Some Causes of Scrotal Pain |
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Cause
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Suggestive Findings
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Diagnostic Approach
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Testicular torsion
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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
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Color Doppler ultrasonography
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Appendiceal torsion (a vesicular nonpedunculated structure attached to the cephalic pole of the testis)
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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
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Color Doppler ultrasonography
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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
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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
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Urinalysis and culture
Nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis
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Postvasectomy, acute and chronic (postvasectomy pain syndrome)
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History of vasectomy
Pain during intercourse, ejaculation, or both
Pain during physical exertion
Tender or full epididymis
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Clinical evaluation
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Trauma
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Clear history of trauma to the genitals
Often swelling, possible intratesticular hematoma or hematocele
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Color Doppler ultrasonography
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Inguinal hernia (strangulated)
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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
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Clinical evaluation
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Henoch-Schönlein purpura
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Palpable purpura (typically of lower extremities and buttocks), arthralgia, arthritis, abdominal pain, renal disease
Typically occurring in boys aged 3–15 yr
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Clinical evaluation
Sometimes biopsy of skin lesions
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Polyarteritis nodosa
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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
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Angiography
Sometimes biopsy of affected organ
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Referred pain (abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, postherniorrhaphy pain)
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Normal scrotal examination
Sometimes abdominal tenderness depending on cause
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Directed by examination findings and suspected cause
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Orchitis (usually viral—eg, mumps; rubella; coxsackievirus, echovirus, or parvovirus infection)
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Scrotal and abdominal pain, nausea, fever
Unilateral or bilateral swelling, erythema of scrotum
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Acute and convalescent viral titers
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Fournier's gangrene (necrotizing fasciitis of the perineum)
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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
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Clinical evaluation
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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 (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's 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:
Interpretation of findings
The focus is to distinguish causes that require immediate treatment from others. Clinical findings provide important clues (see Table 7: Symptoms of Genitourinary Disorders: Some Causes of Scrotal Pain).
Aortic catastrophes and Fournier's 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's gangrene.
A vasculitic rash, abdominal pain, and arthralgias are consistent with a systemic vasculitis syndrome such as Henoch-Schönlein purpura or polyarteritis nodosa.
Testing
Testing is typically done.
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
Last full review/revision September 2009 by Seyed-Ali Sadjadi, MD
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