Testicular pain
Encyclopedia
Testicular pain or scrotal pain is when part or all of either one or both testicles hurt. Pain of the scrotum
is often included. It may be either acute, subacute or chronic depending on its duration. Causes rank from benign muscular skeletal problems to emergent condition
such as Fournier's gangrene and testicular torsion
. Pain management is typically given with definitive management depending on the underlying cause. The diagnostic approach involves making sure no serious conditions are present and may involve the use of ultrasound imaging and laboratory evaluations.
, due to infections such as epididymitis
, prostatitis
, and orchitis
, as well as varicocele
, hydrocele
, spermatocele
, polyarteritis nodosa
, testicular torsion
, previous surgery and trauma. In 25% of cases the cause is never determined. The pain can persist for a long and indefinite period of time following the vasectomy
, in which case it is termed Post-Vasectomy Pain Syndrome
(PVPS).
(16%), torsion of a testicular appendage (46%), and epididymitis
(35%). In adults the most common cause is epididymitis.
usually presents with an acute onset of diffuse testicular pain and tenderness of less than 6 hrs of duration. There is often an absent or decreased cremasteric reflex
, the testicle is elevated, and often is horizontal. It occurs annually in about 1 in 4000 males before 25 years of age, is most frequent among adolescents ( 65% of cases presenting between 12 – 18 years of age ), and is rare after 35 years of age. It is a surgical emergency.
occurs when there is inflammation
of the epididymis
(a curved structure at the back of the testicle
). This condition usually presents with gradual onset of varying degrees of pain, and the scrotum
may be red, warm and swollen. It is often accompanied by symptoms of a urinary tract infection
, fever, and in over half of cases it presents in combination with orchitis
. In those between the ages of 14 to 35 it is usually caused by either gonorrhea
or chlamydia. In people either older or younger E. coli is the most common bacterial infection. Treatment involves the use of antibiotics.
) usually presents with fever and intense pain. It is a rare condition but fatal if not identified and aggressively treated with a combination of surgical debridement
and broad spectrum antibiotics.
s, injury, hydrocele
s, and varicocele
s among others. Testicular cancer
is usually painless. Another potential cause is blue balls
.
( the relief of pain with elevation ) though a classic physical exam finding has not been found to be reliable in distinguishing torsion from other causes of testicular pain such as epididymitis
.
(usually normal in testicular torsion). Pyuria
and bacteriuria
(white blood cells and bacteria in the urine) in patients with acute scrotum suggests an infectious cause such as epididymitis or orchitis and specific testing for gonorrhea and chlamydia should done. All people with chronic pain should be tested for gonorrhea
and chlamydia.
is useful if the cause is not certain based on the above measures. If the diagnosis of torsion is certain imaging should not delay definitive management such as physical maneuvers and surgery.
Scrotum
In some male mammals the scrotum is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly...
is often included. It may be either acute, subacute or chronic depending on its duration. Causes rank from benign muscular skeletal problems to emergent condition
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
such as Fournier's gangrene and testicular torsion
Testicular torsion
Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood supply. The most common symptom is acute testicular pain and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it...
. Pain management is typically given with definitive management depending on the underlying cause. The diagnostic approach involves making sure no serious conditions are present and may involve the use of ultrasound imaging and laboratory evaluations.
Chronic scrotal pain
Chronic scrotal pain (pain for greater than 3 months) may occur due to a number of underlying conditions. It occurs in 15-19% of people post vasectomyVasectomy
Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream...
, due to infections such as epididymitis
Epididymitis
Epididymitis is a medical condition in which there is inflammation of the epididymis . This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen...
, prostatitis
Prostatitis
Prostatitis is an inflammation of the prostate gland, in men. A prostatitis diagnosis is assigned at 8% of all urologist and 1% of all primary care physician visits in the United States.-Classification:...
, and orchitis
Orchitis
Orchitis or orchiditis is a condition of the testes involving inflammation. It can also involve swelling and frequent infection.-Symptoms:Symptoms of orchitis are similar to those of testicular torsion...
, as well as varicocele
Varicocele
Varicocele , also known as varicoscele or varicose seal, is an abnormal enlargement of the vein that is in the scrotum draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis...
, hydrocele
Hydrocele
A hydrocoele denotes a pathological accumulation of serous fluid in a body cavity. It can also be noted as a minor malformation of newborns due to high levels of lead in the mother's blood during pregnancy....
, spermatocele
Spermatocele
Spermatocele is a retention cyst of a tubule of the rete testis or the head of the epididymis distended with barely watery fluid that contains spermatozoa. Spermatoceles are the most common cystic condition encountered within the scrotum. They vary in size from several millimeters to many...
, polyarteritis nodosa
Polyarteritis nodosa
Polyarteritis nodosa is a vasculitis of medium & small-sized arteries, which become swollen and damaged from attack by rogue immune cells. Polyarteritis nodosa is also called Kussmaul disease or Kussmaul-Maier disease...
, testicular torsion
Testicular torsion
Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood supply. The most common symptom is acute testicular pain and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it...
, previous surgery and trauma. In 25% of cases the cause is never determined. The pain can persist for a long and indefinite period of time following the vasectomy
Vasectomy
Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream...
, in which case it is termed Post-Vasectomy Pain Syndrome
Post-Vasectomy Pain Syndrome
Post-vasectomy pain syndrome is a chronic and sometimes debilitating genital pain condition that may develop immediately or several years after vasectomy. Because this condition is a syndrome, there is no single treatment method, therefore efforts focus on mitigating/relieving the individual...
(PVPS).
Differential diagnosis
The differential diagnosis of testicular pain is broad and involves conditions from benign to life threatening. The most common causes of pain in children presenting to the emergency room are testicular torsionTesticular torsion
Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood supply. The most common symptom is acute testicular pain and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it...
(16%), torsion of a testicular appendage (46%), and epididymitis
Epididymitis
Epididymitis is a medical condition in which there is inflammation of the epididymis . This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen...
(35%). In adults the most common cause is epididymitis.
Testicular torsion
Testicular torsionTesticular torsion
Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood supply. The most common symptom is acute testicular pain and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it...
usually presents with an acute onset of diffuse testicular pain and tenderness of less than 6 hrs of duration. There is often an absent or decreased cremasteric reflex
Cremasteric reflex
The cremasteric reflex is a superficial reflex observed in human males.This reflex is elicited by lightly stroking the superior and medial part of the thigh...
, the testicle is elevated, and often is horizontal. It occurs annually in about 1 in 4000 males before 25 years of age, is most frequent among adolescents ( 65% of cases presenting between 12 – 18 years of age ), and is rare after 35 years of age. It is a surgical emergency.
Epididymitis
EpididymitisEpididymitis
Epididymitis is a medical condition in which there is inflammation of the epididymis . This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen...
occurs when there is inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the epididymis
Epididymis
The epididymis is part of the male reproductive system and is present in all male amniotes. It is a narrow, tightly-coiled tube connecting the efferent ducts from the rear of each testicle to its vas deferens. A similar, but probably non-homologous, structure is found in cartilaginous...
(a curved structure at the back of the testicle
Testicle
The testicle is the male gonad in animals. Like the ovaries to which they are homologous, testes are components of both the reproductive system and the endocrine system...
). This condition usually presents with gradual onset of varying degrees of pain, and the scrotum
Scrotum
In some male mammals the scrotum is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly...
may be red, warm and swollen. It is often accompanied by symptoms of a urinary tract infection
Urinary tract infection
A urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...
, fever, and in over half of cases it presents in combination with orchitis
Orchitis
Orchitis or orchiditis is a condition of the testes involving inflammation. It can also involve swelling and frequent infection.-Symptoms:Symptoms of orchitis are similar to those of testicular torsion...
. In those between the ages of 14 to 35 it is usually caused by either gonorrhea
Gonorrhea
Gonorrhea is a common sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. The usual symptoms in men are burning with urination and penile discharge. Women, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain...
or chlamydia. In people either older or younger E. coli is the most common bacterial infection. Treatment involves the use of antibiotics.
Fournier's gangrene
Fournier's gangrene ( an aggressive and rapidly spreading infection of the perineumPerineum
In human anatomy, the perineum is a region of the body including the perineal body and surrounding structures...
) usually presents with fever and intense pain. It is a rare condition but fatal if not identified and aggressively treated with a combination of surgical debridement
Debridement
Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...
and broad spectrum antibiotics.
Others
Many other less common conditions can lead to testicular pain. These include inguinal herniaInguinal hernia
An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. They are very common , and their repair is one of the most frequently performed surgical operations....
s, injury, hydrocele
Hydrocele
A hydrocoele denotes a pathological accumulation of serous fluid in a body cavity. It can also be noted as a minor malformation of newborns due to high levels of lead in the mother's blood during pregnancy....
s, and varicocele
Varicocele
Varicocele , also known as varicoscele or varicose seal, is an abnormal enlargement of the vein that is in the scrotum draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis...
s among others. Testicular cancer
Testicular cancer
Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system.In the United States, between 7,500 and 8,000 diagnoses of testicular cancer are made each year. In the UK, approximately 2,000 men are diagnosed each year. Over his lifetime, a man's risk of...
is usually painless. Another potential cause is blue balls
Blue balls
Blue balls is a slang term for the condition of temporary fluid congestion in the testicles and prostate region, accompanied by acute testicular pain, caused by prolonged and unsatisfied sexual arousal in the human male. The term is thought to have originated in the United States, first appearing...
.
Physical findings
The cremaster reflex (elevation of the testicle in response to stroking the upper inner thigh) is typically present in epididymitis but absent in testicular torsion as the testis is already elevated. Prehn's signPrehn's sign
Prehn's sign is a medical diagnostic indicator that was once believed to help determine whether the presenting testicular pain is caused by acute epididymitis or from testicular torsion...
( the relief of pain with elevation ) though a classic physical exam finding has not been found to be reliable in distinguishing torsion from other causes of testicular pain such as epididymitis
Epididymitis
Epididymitis is a medical condition in which there is inflammation of the epididymis . This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen...
.
Laboratory tests
Useful tests that may help in the determination of the cause include a urinalysisUrinalysis
A urinalysis , also known as Routine and Microscopy , is an array of tests performed on urine, and one of the most common methods of medical diagnosis...
(usually normal in testicular torsion). Pyuria
Pyuria
In medicine, Pyuria refers to urine which contains pus. Defined as the presence of 4 or more neutrophils per high power field of unspun, voided mid-stream urine. It can be sign of a bacterial urinary tract infection...
and bacteriuria
Bacteriuria
In medicine, bacteriuria denotes the presence of bacteria in urine not due to contamination from urine sample collection.Urine is normally a sterile bodily fluid when inside the bladder, but can pick up commensals and pathogens when exiting through the urethra...
(white blood cells and bacteria in the urine) in patients with acute scrotum suggests an infectious cause such as epididymitis or orchitis and specific testing for gonorrhea and chlamydia should done. All people with chronic pain should be tested for gonorrhea
Gonorrhea
Gonorrhea is a common sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. The usual symptoms in men are burning with urination and penile discharge. Women, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain...
and chlamydia.
Imaging
UltrasoundMedical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
is useful if the cause is not certain based on the above measures. If the diagnosis of torsion is certain imaging should not delay definitive management such as physical maneuvers and surgery.