Scrotal pain can occur in males of any age, from neonates to older men.
Etiology of Scrotal Pain
The most common causes of scrotal pain include
There are a number of less common causes (see table Some Causes of Scrotal Pain Some Causes of Scrotal Pain Scrotal pain can occur in males of any age, from neonates to older men. The most common causes of scrotal pain include Testicular torsion Torsion of the testicular appendage Epididymitis/epididymo-orchitis read more ). Age, onset of symptoms, and other findings can help determine the cause.
Evaluation of Scrotal Pain
Expeditious evaluation, diagnosis, and treatment are required because untreated testicular torsion Testicular Torsion Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting... read more 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 Immunoglobulin A–Associated Vasculitis (IgAV) Immunoglobulin A–associated vasculitis (formerly called Henoch-Schönlein purpura) is vasculitis that affects primarily small vessels. It occurs most often in children. Common manifestations... read more 
[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 Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more ).
Past medical history should identify known disorders that may cause referred pain, including hernias, abdominal aortic aneurysm Abdominal Aortic Aneurysms (AAA) Abdominal aortic diameter ≥ 3 cm typically constitutes an abdominal aortic aneurysm. The cause is multifactorial, but atherosclerosis is often involved. Most aneurysms grow slowly (~10%/year)... read more 
, 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:
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Sudden onset of pain; exquisite tenderness; and a high-riding, horizontally displaced testis (testicular torsion Testicular Torsion Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting... read more )
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Inguinal or scrotal nonreducible mass with severe pain, vomiting, and constipation (incarcerated hernia)
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Scrotal or perineal erythema, necrotic or blistered skin lesions, and toxic appearance (Fournier gangrene)
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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 Some Causes of Scrotal Pain Scrotal pain can occur in males of any age, from neonates to older men. The most common causes of scrotal pain include Testicular torsion Torsion of the testicular appendage Epididymitis/epididymo-orchitis read more ).
Aortic catastrophes and Fournier gangrene occur primarily in patients aged > 50 years; 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 years), and epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more 
is most common in adolescents and adults.
Severe, sudden onset of pain suggests testicular torsion or renal calculus Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more . Pain from epididymitis, incarcerated hernia, or appendicitis Appendicitis Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasonography... read more 
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 aged > 55 years, 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 Abdominal Aortic Aneurysms (AAA) Abdominal aortic diameter ≥ 3 cm typically constitutes an abdominal aortic aneurysm. The cause is multifactorial, but atherosclerosis is often involved. Most aneurysms grow slowly (~10%/year)... read more .
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 Overview of Sexually Transmitted Diseases Sexually transmitted diseases (STDs), also termed sexually transmitted infections (STIs), can be caused by a number of microorganisms that vary widely in size, life cycle, the diseases and symptoms... read more (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 Cellulitis Cellulitis is acute bacterial infection of the skin and subcutaneous tissue most often caused by streptococci or staphylococci. Symptoms and signs are pain, warmth, rapidly spreading erythema... read more 
or early Fournier gangrene.
A vasculitic rash, abdominal pain, and arthralgias are consistent with a systemic vasculitis syndrome such as immunoglobulin A–associated vasculitis Immunoglobulin A–Associated Vasculitis (IgAV) Immunoglobulin A–associated vasculitis (formerly called Henoch-Schönlein purpura) is vasculitis that affects primarily small vessels. It occurs most often in children. Common manifestations... read more or polyarteritis nodosa Polyarteritis Nodosa (PAN) Polyarteritis nodosa is a systemic necrotizing vasculitis that typically affects medium-sized muscular arteries and occasionally affects small muscular arteries, resulting in secondary tissue... read more .
Testing
Testing is typically done.
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Urinalysis and culture (all patients)
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STD testing (all patients with positive urinalysis, discharge, or dysuria)
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Color Doppler ultrasonography to rule out torsion (no clear-cut alternate cause)
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Other testing as suggested by findings (see table Some Causes of Scrotal Pain Some Causes of Scrotal Pain Scrotal pain can occur in males of any age, from neonates to older men. The most common causes of scrotal pain include Testicular torsion Torsion of the testicular appendage Epididymitis/epididymo-orchitis read more )
Urinalysis and culture are always required. Findings of urinary tract infection (UTI—eg, pyuria, bacteriuria) suggest epididymitis. Patients with findings that suggest UTI and patients with urethral discharge or dysuria Dysuria Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely common symptom... read more 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 Doppler In ultrasonography, a signal generator is combined with a transducer. Piezoelectric crystals in the signal generator convert electricity into high-frequency sound waves, which are sent into... read more 
is done. If Doppler ultrasonography is not available, radionuclide scanning Radionuclide Scanning Radionuclide scanning uses the radiation released by radionuclides (called nuclear decay) to produce images. A radionuclide is an unstable isotope that becomes more stable by releasing energy... read more 
may be used but is less sensitive and specific.
Treatment of Scrotal Pain
Treatment is directed at the cause and can range from emergency surgery (testicular torsion Testicular Torsion Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting... read more ) to bed rest (torsion of the testicular appendage). If testicular torsion is present, prompt surgery (< 12 hours 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 Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more or orchitis Orchitis Orchitis is infection of the testes, typically with mumps virus. Symptoms are testicular pain and swelling. Diagnosis is clinical. Treatment is symptomatic. Antibiotics are given only if bacterial... read more .
Geriatrics Essentials
Testicular torsion is uncommon in older men, and when present, the manifestations are usually atypical and therefore diagnosis is delayed. Epididymitis, orchitis, and trauma are more common in older men. Occasionally, inguinal hernia Hernias of the Abdominal Wall A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more 
, colon perforation Acute Perforation of the Gastrointestinal Tract Any part of the gastrointestinal tract may become perforated, releasing gastric or intestinal contents into the peritoneal space. Causes vary. Symptoms develop suddenly, with severe pain followed... read more 
, or renal colic may cause scrotal pain in older men.
Key Points
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Always consider testicular torsion in patients with acute scrotal pain, particularly in children and adolescents; quick, accurate diagnosis is essential.
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Other common causes of scrotal pain are torsion of the testicular appendage and epididymitis.
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Color Doppler ultrasonography is usually done when the diagnosis is unclear.
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Normal findings on scrotal and perineal examination suggest referred pain.
