Some Causes of Scrotal Pain
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
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 | ||
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 years | |
Epididymitis or epididymo-orchitis, usually infectious, with gram-negative organisms in prepubertal boys and older men or, in sexually active men, sexually transmitted infection 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 | |
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 years | Clinical evaluation Sometimes biopsy of skin lesions |
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 years | 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 |