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Scrotal Pain

By

Geetha Maddukuri

, MD, Saint Louis University

Last full review/revision Jan 2021| Content last modified Jan 2021
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Scrotal pain can occur in males of any age, from neonates to older men.

Etiology of Scrotal Pain

Evaluation of Scrotal Pain

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.

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 Abdominal Aortic Aneurysms (AAA) , 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:

Interpretation of findings

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 Epididymitis 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 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 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 Abdominal Aortic Aneurysms (AAA) .

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 Cellulitis or early Fournier gangrene.

Testing

Testing is typically done.

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 Doppler 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 Radionuclide Scanning 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.

Geriatrics Essentials

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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