Acute Scrotal Pain in Adults and Adolescents - Approach To The Patient - DynaMed

18/9/23, 19:14 Acute Scrotal Pain in Adults and Adolescents - Approach to the Patient - DynaMed
APPROACH TO PATIENT
Updated 16 May 2022
Acute Scrotal Pain in Adults and Adolescents - Approach to the

Patient
Overview and Recommendations
Background
● Acute scrotal pain refers to the sudden onset of testicular pain, with or without swelling, whereas chronic
scrotal pain typically refers to constant or intermittent pain that lasts ≥ 3 months and interferes with
daily activities.
● Acute scrotal pain may be caused by vascular disruptions (ischemia) to the scrotal tissue, infection or
inflammation (either local or systemic), trauma involving the genitourinary tract, or other scrotal or
nonscrotal causes.
⚬ Common scrotal causes include testicular torsion, acute epididymitis, hydrocele, varicocele,
spermatocele, and scrotal trauma.
⚬ Common nonscrotal causes include inguinal hernia and kidney colic.
● Acute scrotal pain is reported to be a relatively common presentation in emergency and acute care
settings, and it is reported to account for about 1% of emergency department visits.
● Acute scrotal pain is considered an emergency when it is due to causes requiring prompt medical or
surgical intervention, such as testicular torsion (which may result in loss of testicular function if the blood
supply to the testicles is not restored in 6 hours or less), Fournier gangrene (which, albeit infrequently
occurring, has a reportedly high mortality rate), traumatic testicular rupture, incarcerated or strangulated
hernia, and testicular cancer.
Evaluation
● Acute scrotal pain requires careful history and physical examination to determine the underlying cause
of pain.
● Many causes have similar or overlapping features at presentation.
⚬ Sudden onset of pain may occur in testicular torsion, Fournier gangrene, and, less often, in acute
epididymitis (which is typically characterized by a more gradual onset of pain).
⚬ Testicular or scrotal swelling may occur in testicular torsion, acute epididymitis, mumps orchitis,
Fournier gangrene, and acute idiopathic scrotal edema.
⚬ A palpable testicular mass may occur in testicular cancer, hydrocele, varicocele, and inguinal hernia.
⚬ Systemic or extratesticular features such as nausea and vomiting may be present in testicular torsion
and kidney colic.
Table 1: Clinical Presentation of Causes of Acute Scrotal Pain
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Symptoms Findings on Associated

Physical Exam Findings
Testicular torsion – Sudden onset – High-riding or – Previous

of severe pain horizontal episodes of
– Unilateral pain testis testicular pain
and swelling (retracted – Onset at
– Associated upwards) waking from
nausea and – Epididymis sleep or during
vomiting may be felt in sporting
– Possible anterior activity
abdominal position
pain – Absent
cremasteric
reflex
– Thickened
spermatic cord
– Red/blue skin
discoloration
Traumatic – Pain – Findings Recent trauma

testicular – Swelling depend on
rupture/hematoc – Ecchymosis mechanism
ele – Possible and extent of
nonintact skin injury
– Testicular
rupture
Acute – Gradual onset – Focal Recent history of:

epididymitis of symptoms tenderness – Urinary tract
(acute over 1-2 days – Pain decreases procedures
epididymo- – Dull unilateral with elevation – Urinary tract
orchitis) pain (Prehn sign) infection
– Early, localized – Fever – Sexually
pain to – Possible transmitted
posterior testis findings: infections or
– Fever ● Tachypnea sexual activity

Symptoms of UTI ● Tachycardia – Viral illness

or STI: ● Hypotensio
n
– Dysuria
● Hematuria
– Frequent
● Parotid
urination
swelling
– Urethral
(mumps)
discharge
Fournier – Severe pain – Fever, – Local trauma

gangrene – Fever and tachycardia, – Possible
malaise tachypnea, presence of
– Worsening and associated
pruritus, pain, hypotension factors such
and discomfort – Subcutaneous as:
over 3-5 days crepitus ● Diabetes
(hallmark of ● HIV
condition) ● Steroid use
– Purulent disorder
drainage and ● Alcohol use
patches of disorder
necrotic tissue ● Malignancy
with ● Lymphoprol
surrounding iferative
edema disease
– Later stages of ● Recent
disease: bullae instrumenta
and skin tion,
sloughing off catheterizati
– On palpation, on, and
affected area perineal
is hard and trauma
wooden
– Blue/purple
discoloration

and violaceous
plaques
Incarcerated Severe pain over – Unable to feel N/A

inguinal hernia swelling/mass in spermatic cord
groin above lump
– Present cough
impulse
– Irreducible
Testicular cancer – Usually, – Mass/swelling Risk factor:

painless cannot be testicular
scrotal mass separated maldescent
– If pain present, from the testis
may be dull – Gynecomastia
ache or heavy may be
sensation in present
the lower
abdomen
Abbreviations: N/A, not applicable; STI, sexually transmitted infection; UTI, urinary tract infection.
References -
Abdom Radiol (NY) 2020 Jul;45(7):2063, J R Nav Med Serv 2016;102(1):40, BMJ 2015 Apr
2;350:h1563, Korean J Urol 2015 Jan;56(1):3.
● Prompt diagnosis of the underlying cause is necessary to rule out causes that represent a medical
emergency and require immediate treatment. In particular, testicular torsion should be considered for all
patients presenting with acute scrotal pain since prompt assessment and treatment are essential to
preserve the testicular function.
● The diagnostic approach may vary based on suspected cause, including:
⚬ vascular disruptions such as testicular torsion, torsion of testicular appendage, or segmental

testicular infarction
⚬ infection or inflammation such as acute epididymitis, Fournier gangrene, Henoch-Schonlein purpura,
Behcet syndrome, or polyarteritis nodosa
⚬ trauma
⚬ other urologic or scrotal causes such as testicular cancer, hydrocele, varicocele, or spermatocele
⚬ nonscrotal causes such as incarcerated or strangulated hernia or kidney colic
Table 2: Summary of Findings on Diagnostic Testing of Causes of Acute Scrotal Pain
Diagnostic Findings on Findings on

Modalities Laboratory Ultrasound/Colo
Testing r Doppler
Testicular torsion – Clinical Normal urinalysis – Early finding:

diagnosis (does not exclude decreased or
– Confirmed diagnosis) absent venous
with surgery or blood flow
ultrasound – Later finding:
decreased or
absent arterial
flow
– Testicular
enlargement,
heterogeneity,
and
hypoechogenic
ity
representing
edema
– Twisting of
spermatic
cord, scrotal
skin
thickening,
and secondary
hydrocele may
also be seen
Traumatic – For blunt Possible – Heterogeneou

testicular trauma: hematuria on s-appearing
rupture/hematoc ultrasound urinalysis with testicle with
ele polytrauma discontinuity
– For
Diagnostic Findings on of surrounding
Findings on
penetrating
Modalities Laboratory tunica
Ultrasound/Colo
trauma: Testing albuginea
r Doppler
exploratory – Indistinct
surgery testicular
margins
– Loss of
vascularity to
part of or
entire affected
testicle
– Hematocele
usually
present
– Testicle may
be fragmented
Acute – Diagnosis May have positive – Performed to

epididymitis based on findings on: rule out
(acute clinical and – Urinalysis testicular
epididymo- laboratory (indicating UTI) torsion
orchitis) findings – Urine cultures – Increased
– Urinalysis – Urethral blood flow to
– Midstream cultures testes and/or
catch for – Blood cultures epididymis
microscopy – Enlarged,
and culture hypoechoic
– Urethral epididymis
culture – Reactive
– Immunoglobuli hydrocele
n levels (if – Scrotal wall
mumps thickening
suspected)
– color Doppler
ultrasound
Fournier – Diagnosis – Leukocytosis Findings include:

gangrene confirmed at or leukopenia
surgery
Diagnostic
– Evidence
Findings of
on
– Diffuse
Findings on
– Blood tests
Modalities hemolysis,
Laboratory subcutaneous
Ultrasound/Colo
including CBC, such as falling
Testing tissue
r Doppler
coagulation hemoglobin thickening
studies, with stable – Perifascial fluid
metabolic hematocrit accumulation
panel, LFTs, – Hematocrit < – Bright
lactate, CRP, 20% or > 60% echogenic foci
creatinine – Thrombocytop with dirty
kinase, arterial enia shadowing
blood gas – Acute kidney – Reverberation
– Blood cultures failure artifacts
– Baseline – Hypocalcemia corresponding
immunoglobuli – Hyponatremia to underlying
n levels – Hypokalemia soft tissue gas
– Computed – Hypomagnese
tomography mia
– Low albumin
– Elevated
glucose
– Elevated
serum lactate
– Metabolic
acidosis
– Elevated CRP
– Elevated
creatinine
kinase
– See Diagnosis
in Necrotizing
Fasciitis
Incarcerated – Clinical N/A – Sonographic

inguinal hernia diagnosis appearance
– Ultrasound if depends on
diagnosis hernial sac
unclear contents

Testing r Doppler
– Most
commonly
contains
bowel,
followed by
omentum
– Grayscale
findings show
fluid- or air-
filled loop of
bowel in the
scrotum
– Bowel
strangulation
appears as
akinetic dilated
loops of bowel
– Hyperemia of
scrotal soft
tissue and
bowel wall
suggests
strangulation
Testicular cancer – Diagnosis May have positive Well-defined,

confirmed by tumor markers: hypoechoic or
histology – Beta-hCG heterogeneous
– Testicular – LDH echogenic
ultrasound – AFP intratesticular
– Blood tests – See Diagnosis lesions
including CBC, and Staging in
electrolytes Testicular Cancer
and creatinine,
LFTs, and

Testing r Doppler
serum tumor
markers (beta-
hCG, LDH, and
AFP)
– Biopsy
Abbreviations: AFP, alpha fetoprotein; Beta-hCG, beta-human chorionic gonadotropin; CBC,

complete blood count; CRP, C-reactive protein; LDH, lactate dehydrogenase; LFTs, liver function
tests; N/A, not applicable; UTI, urinary tract infection.
References -
Radiol Clin North Am 2004 Mar;42(2):349, Abdom Radiol (NY) 2020 Jul;45(7):2063, J R Nav Med
Serv 2016;102(1):40, BMJ 2015 Apr 2;350:h1563, Korean J Urol 2015 Jan;56(1):3, American
Urological Association (AUA) Urotrauma Guideline 2020 Aug , Arch Ital Urol Androl 2016 Oct
5;88(3):157.
Management
● Management of acute scrotal pain mainly consists of treating the underlying cause of pain.
● The following causes of acute scrotal pain typically require emergent or urgent management, which may
include surgical exploration or repair, referral to specialist (urologist), and/or initiation of antimicrobial
therapy.
⚬ For testicular torsion, management options include immediate scrotal exploration, detorsion, and
orchidopexy. Torsion of testicular appendage may not necessarily require surgical intervention.
⚬ For traumatic testicular rupture, management options include surgical exploration, orchidopexy,
orchiectomy, and reconstruction; conservative management (including scrotal support, analgesics,
and ice packs) may be appropriate for small hematocele (< 3 times the size of contralateral testis) and
testicular dislocation.
⚬ For acute epididymitis (and acute epididymo-orchitis), treatment includes antibiotic therapy.
⚬ For Fournier gangrene, mainstays of care are prompt and complete surgical debridement combined
with immediate and aggressive antimicrobial therapy.
⚬ For incarcerated or strangulated hernia, urgent surgical referral is required; however, small, reducible
hernia may not require urgent surgery.
⚬ For testicular cancer, prompt urologic referral is required; management depends on type of testicular
cancer and clinical stage, and options include surgery, chemotherapy, radiation therapy, or
surveillance.
● Other causes of acute scrotal pain do not typically require urgent treatment and may be managed with
surgical exploration or repair, referral to specialist (urologist), initiation of medical therapy, or
surveillance.
⚬ For segmental testicular infarction, management was historically based on surgery, but conservative
management has been reported in patients with high certainty of diagnosis (once testicular cancer
has been ruled out).
⚬ For Behcet syndrome, management depends on the affected organs, the severity of the disease, and
other patient characteristics; it may include topical treatment (including local corticosteroids) or
systemic therapies (such as colchicine, cyclosporine A, azathioprine, interferon alfa, and tumor
necrosis factor alpha antagonists).
⚬ For hydrocele, management depends on the presence or absence of symptoms and includes watchful
waiting, surgery, or aspiration and sclerotherapy.
⚬ For varicocele, surgical management is controversial; considerations for surgery include recurrence,
size of varicocele, and presence of symptoms.
⚬ For spermatocele, intervention is likely not required if asymptomatic; if symptomatic, referral for
consideration of surgical excision may be appropriate.
Related Topics
● Testicular Torsion
● Acute Epididymitis
● Necrotizing Fasciitis
● Traumatic Genitourinary Tract Injuries in Adults
● Testicular Cancer
● Henoch-Schonlein Purpura
● Varicocele in Children and Adolescents
● Varicocele in Adults
● Hydrocele in Adults and Adolescents
General Information
Description
● acute scrotal pain may be caused by vascular disruptions causing ischemia to scrotal tissue, infection or
inflammation (local or systemic), trauma involving the genitourinary tract, or other scrotal or nonscrotal
causes (referred pain)
● vascular causes include
⚬ testicular torsion, which is a common cause and requires urgent medical attention
⚬ torsion of testicular appendix
⚬ segmental infarction
● infectious or inflammatory causes include
⚬ epididymitis, acute epididymo-orchitis, and orchitis

⚬ Fournier gangrene (which requires urgent medical attention)
⚬ sterile epididymitis
⚬ Henoch-Schonlein purpura
⚬ Behcet syndrome
⚬ polyarteritis nodosa
● scrotal and testicular trauma include
⚬ blunt trauma such as testicular rupture and hematocele

⚬ genital burns
● other scrotal-related causes may include
⚬ testicular cancer
⚬ hydrocele
⚬ varicocele
⚬ spermatocele
⚬ idiopathic scrotal edema
● nonscrotal causes include
⚬ kidney colic and ureteral stones

⚬ inguinal hernia
⚬ inflammation or infection of nonurologic abdominal or pelvic structures, such as acute appendicitis,
acute pancreatitis, or peritonitis
⚬ ruptured abdominal aortic aneurysm and retroperitoneal hemorrhage
⚬ retroperitoneal tumors
⚬ other nonscrotal causes of acute scrotal pain
Definitions
● acute scrotal pain refers to sudden onset of testicular pain with or without swelling 2
● chronic scrotal pain refers to constant or intermittent pain lasting ≥ 3 months and that interferes with
1
daily activities
Also Called
● acute scrotum
Incidence/Prevalence
● acute scrotal pain described as common presentation in emergency and urgent care setting (Emerg
Radiol 2018 Aug;25(4):341)
● acute scrotal pain reported to be common presentation for medical care in adolescents and children 2
● painful scrotum reported to account for 1% of emergency department visits (Am Fam Physician 2014
May 1;89(9):723)
● incidence/prevalence of some causes of acute scrotal pain
⚬ testicular torsion - reported incidence 1 per 4,000 male patients < 25 years old 1 ,2
⚬ acute epididymitis - reported incidence 25 per 100,000 person-years in United Kingdom general
practice in 2004-2005 (Practitioner 2013 Apr;257(1760):21)
⚬ Fournier gangrene - reported overall incidence 1.6 cases per 100,000 male patients per year and
reported incidence 3.3 per 100,000 male patients per year in male adults > 50 years old (Arch Ital Urol
Androl 2016 Oct 5;88(3):157)
⚬ trauma-related
– incidence of scrotal or testicular damage < 1% (0.23%) of 3,489,850 injuries in male trauma patients
from the National Trauma Data Bank from 2007 to 2015 (Res Rep Urol 2018;10:51)
– annual incidence of genital burns 3.27 per 1,000,000 persons from National Electronic Injury
Surveillance System database from 2000 to 2016 (Burns 2018 Aug;44(5):1366)
⚬ hydrocele
– in adults, noticeable hydrocele reported in about 1% of male persons

– acquired reactive hydrocele post varicocelectomy reported in 0%-24% of patients depending on
surgical technique
– acquired chronic hydrocele due to lymphatic (bancroftian) filariasis reported in 20%-30% of male
persons in endemic regions of Africa
– References - Nat Rev Urol 2010 Jul;7(7):379, Prim Care 2010 Sep;37(3):613
⚬ spermatocele - reported to be 1 of the most common adult urologic diagnoses and may be present in
up to 30% of patients (BJU Int 2011 Jun;107(11):1852)
⚬ varicocele - reported incidence in 10%-20% in general male population and 2%-20% in male
adolescents; pain secondary to varicocele estimated to affect 2%-10% of male adults 1 , 2 , 3
⚬ nonscrotal causes
– acute pancreatitis - global incidence estimate 34 cases per 100,000 person-years (Lancet
Gastroenterol Hepatol 2016 Sep;1(1):45)
– abdominal aortic aneurysm rupture - reported incidence 12 per 100,000 persons (Nat Rev Dis
Primers 2018 Oct 18;4(1):34)
– inguinal hernia
● 5%-7% estimated prevalence of nonsurgically treated hernias in United States population (Am J
Epidemiol 2007 May 15;165(10):1154)
● incarceration or strangulation of hernia reported to occur in up to 5% of cases 3
– kidney colic
● incidence of nephrolithiasis depends on geographic, climatic, ethnic, dietary, and genetic factors
● reported lifetime prevalence of nephrolithiasis varies from 1% to 20%
● Reference - European Association of Urology (EAU) guideline on urolithiasis EAU 2022 Mar
Differential Diagnosis
Causes Requiring Urgent Medical or Surgical Intervention
● acute scrotal pain considered an emergent condition, as some causes require immediate medical or
surgical intervention to prevent
⚬ significant morbidity - for example, loss of testicular function in the setting of delayed diagnosis of
testicular torsion 1 ,3
⚬ mortality - for example, in setting of fulminant development and progressive tissue necrosis resulting
4
in Fournier gangrene, which has a reported 15%-50% mortality rate
● causes typically requiring urgent intervention include 1 ,2 ,3 ,4
⚬ testicular torsion
⚬ traumatic testicular rupture
⚬ acute epididymitis and acute epididymo-orchitis (requires prompt medical treatment and
investigation to differentiate from testicular torsion)
⚬ Fournier gangrene (necrotizing infections of the perineum or external genitalia)
⚬ incarcerated or strangulated inguinal hernia
⚬ testicular cancer (requires prompt referral and investigation)
Causes According to Frequency
● most common causes, reported to account for > 85% of cases, include 1 ,2
⚬ testicular torsion (typically occurs in male adolescents aged 12-18 years)

⚬ torsion of testicular appendage (appendix testis) (occurs in male adolescents and children; rarely in
persons > 20 years old, more commonly in those aged 7-13 years) 1 , 4
⚬ acute epididymitis (typically occurs in male adults)
● other causes may include
⚬ strangulated inguinal hernia - reported to occur in 5% of cases

⚬ acute idiopathic scrotal edema - rare in adults
⚬ ruptured aortic aneurysm and retroperitoneal hemorrhage - rarely, acute scrotal pain is the first
clinical presentation of ruptured aneurysm of the aorta and common iliac artery
⚬ retroperitoneal tumors such as liposarcomas and leiomyosarcomas (soft tissue sarcomas) - rare
presentation with acute scrotal pain has been reported (pain attributed to compression, stretching,
dislocation, and infiltration of the neuronal ganglia and both autonomic and somatic routes
innervating the testes)
⚬ acute pancreatitis - rarely presents with only isolated acute scrotal pain
⚬ References - 3 ,4 , J Ultrasound Med 2021 Mar;40(3):597
Causes According to Mechanism
Vascular Disruptions (Ischemia)
● testicular torsion 1 ,2 ,3 ,4
⚬ typically occurs in male adolescents aged 12-18 years

⚬ twisting of processus vaginalis and its contents results in necrosis and absence of blood flow within
testis, epididymis, and spermatic cord
– complete torsion refers to obstruction of both arterial and venous blood flow
– partial torsion can occur when spermatic cord is rotated < 450 degrees, which allows some arterial
blood flow
– intermittent torsion characterized by short periods (< 2 hours) of acute-onset unilateral scrotal
pain that spontaneously resolves and recurs
⚬ torsion, in most cases, initially compromises venous return; as edema develops over time, arterial
flow is reduced or occluded
⚬ testicular torsion can be classified as intravaginal, extravaginal, or mesorchial
– intravaginal torsion
● usually due to congenital malformation of processus vaginalis

● "bell-clapper" testicle, wherein tunica vaginalis completely envelopes testis and epididymis, may
predispose to intravaginal torsion; testicle is more horizontally oriented and can rotate more
freely around an axis
– mesorchial torsion (extremely rare) occurs as a result of anomalies in the mesothelium that covers
anterior half of testis and suspends it from vasculature and epididymis
⚬ see Testicular Torsion for additional information
● torsion of testicular appendix (cyst of Morgagni) 2 ,4
⚬ testicular appendage is a small embryologic remnant at upper pole of testis

⚬ torsion can occur spontaneously, resulting in ischemia and pain
⚬ reported to mainly occur in prepubertal male children and adolescents
● segmental infarction due to other vascular insult such as cord injury, thrombosis, or vasculitis 4
⚬ rare entity; most reported cases causing scrotal pain occur in male adults aged 20-40 years
⚬ partial ischemic process that can occur as a sequela of
– recent surgery
– scrotal infection
– hematologic disorders such as sickle cell disease, polycythemia, or vasculitis
Infection and Inflammation
Acute Epididymitis, Acute Epididymo-orchitis, and Orchitis
● epididymitis refers to inflammation of the epididymis, with or without infection, with symptoms lasting <
6 weeks 3 ,4
● orchitis refers to inflammation of the testes alone 3 ,4
● epididymo-orchitis refers to concurrent inflammation of the epididymis and testes, present in > 50% of
3,4
cases
● etiology
⚬ in sexually active patients < 35 years old, often caused by sexually transmitted infection
– most commonly Neisseria gonorrhoeae or Chlamydia trachomatis

– enteric organisms, such as Escherichia coli, are common causes in men having insertive anal
intercourse
– Ureaplasma urealyticum and Mycoplasma genitalium are uncommon
⚬ in patients > 35 years old
– bacteriuria often occurs secondary to obstruction of the urinary tract, surgery or other
instrumentation, systemic disease, and/or immunosuppression
– acute epididymitis often caused by urinary tract pathogens
● most commonly caused by E. coli

● less common causes include Proteus spp., Klebsiella pneumoniae, and Pseudomonas aeruginosa
● rare causes include Salmonella spp. and Staphylococcus aureus
⚬ other uncommon infectious causes include
– bacteria
● Haemophilus influenzae
● Brucella spp.
● Nocardia asteroides
● Treponema pallidum (causative agent of syphilis)
● polymicrobial as with Fournier gangrene
– additional atypical bacteria, although more commonly associated with chronic infection, such as
● Mycobacterium tuberculosis
● Mycobacterium leprae
● bacillus Calmette-Guerin therapy for bladder cancer
– viruses
● mumps (most common cause of isolated orchitis, especially in children)

● mumps vaccination
● coxsackie viruses
● cytomegalovirus (particularly in immunocompromised hosts)
– pathogens causing acute epididymitis more often associated with chronic disease in
immunocompromised patients, such as those with HIV, such as
● fungi
⚬ Candida spp. (commonly Candida albicans, less commonly Candida glabrata)

⚬ Aspergillus fumigatus
⚬ endemic fungi, including Blastomyces dermatitidis, Histoplasma capsulatum, and Coccidioides
immitis
● parasites such as Schistosoma haematobium, Schistosoma mansoni, Toxoplasma gondii, and

Wuchereria bancrofti
⚬ rare noninfectious causes include
– amiodarone
– inflammatory conditions
● Behcet syndrome
● polyarteritis nodosa
● Henoch-Schonlein purpura
● granulomatous orchitis
⚬ see Etiology and Pathogenesis in Acute Epididymitis for additional information
Fournier Gangrene (Type of Necrotizing Fasciitis)
● refers to necrotizing infections of the external genitalia and perineum
● while speed of development and clinical features may be specific to infecting agent, pathogenesis is
similar among all types of necrotizing fasciitis, with common processes including
⚬ introduction of infecting agent to the affected tissue planes
– via initial trauma to skin during injury or surgery

– via hematogenous spread
⚬ rapid spread of infection across tissue planes, leading to
– vascular occlusion
– ischemia
– tissue necrosis
– crepitus, in infections with gas-forming or anaerobic organism
● infections may be polymicrobial or monomicrobial
⚬ polymicrobial infections with both aerobic and anaerobic organisms comprise approximately
70%-80% of cases; bowel flora comprise majority of infecting organisms
⚬ monomicrobial infections comprise 20%-30% of cases; examples of infecting organisms include
– Group A Streptococcus - most common cause of monomicrobial infection

– S. aureus; methicillin-resistant S. aureus is an emerging cause of necrotizing fasciitis
– those that are typically community acquired
● see Necrotizing Fasciitis for additional information
Sterile Epididymitis
● associated with antiarrhythmic agent amiodarone; mechanism unknown but related to high
concentrations of amiodarone accumulated in testicular tissue 1
● reported frequency 11% of adults receiving an antiarrhythmic agent; rarely observed in children 1
Henoch-Schonlein Purpura
● acute systemic immune-mediated small vessel vasculitis characterized by
⚬ nonthrombocytopenic palpable purpura and ≥ 1 of the following
– abdominal pain
– acute arthritis or arthralgia
– kidney involvement (proteinuria or hematuria)
– IgA-predominant deposits on biopsy (usually skin or kidney)
⚬ self-limited course but with persistent kidney sequelae in some patients

⚬ References - Eur J Pediatr 2010 Jun;169(6):643, Acta Derm Venereol 2017 Nov 15;97(10):1160
● causes
⚬ IgA immune complexes deposit in small vessels triggered by exposure to certain antigens
⚬ hypotheses include genetic predisposition combined with antigenic stimulus (such as infections,
drugs, or toxins) triggering the disease
⚬ References - Eur J Pediatr 2010 Jun;169(6):643, Acta Derm Venereol 2017 Nov 15;97(10):1160
● common drugs associated with Henoch-Schonlein purpura in adults include
⚬ angiotensin-converting enzyme inhibitors

⚬ angiotensin II receptor antagonists
⚬ antibiotics
⚬ nonsteroidal anti-inflammatory drugs
⚬ Reference - Int J Dermatol 2009 Nov;48(11):1157
● scrotal involvement reported in 2%-38% of patients 1
● see Henoch-Schonlein Purpura for additional information
Behcet Syndrome
● systemic vasculitis affecting small and large vessels of venous and arterial systems, characterized by
relapsing episodes of inflammation
● usually develops between ages 20 and 39 years and is most common in Asia, Eastern Mediterranean
region, and the Middle East
● cause is unknown but theorized to involve an autoimmune process triggered by an infectious or

environmental agent (possibly specific to particular geographic location) in a genetically predisposed
person
● genital ulcers reported in 60%-90% of patients; can occur anywhere in genitourinary tract, but most
commonly occur on scrotum in male patients
● see Behcet Syndrome for more information
Polyarteritis Nodosa
● ⚬ necrotizing arteritis primarily affecting medium-sized arteries such as the main visceral arteries and
their branches
⚬ may be triggered by hepatitis B, or possibly other viruses, but most cases of polyarteritis nodosa are
idiopathic
⚬ see Polyarteritis Nodosa for more information
Trauma
● male young adults most affected (Emerg Med Pract 2017 Aug;19(8):1)
● causes of genitourinary tract trauma
⚬ motor vehicle accidents, including off-road cycling and motorbiking

⚬ falls
⚬ contact sports such as rugby, football, and hockey without the use of protective aids
⚬ bicycle accidents
⚬ gunshot wounds
⚬ wound from knife or other sharp object
⚬ sexual intercourse
⚬ childbirth
⚬ assault
⚬ improvised explosive devices (combat-related injuries)

⚬ genital burns (thermal or chemical)
⚬ self-inflicted
⚬ genitourinary foreign bodies
⚬ trauma related to genital piercings
⚬ human and animal bites
⚬ iatrogenic causes during medical and surgical procedures
⚬ see Etiology and Pathogenesis in Traumatic Genitourinary Tract Injuries in Adults for additional
information
● scrotum and testicular trauma
⚬ blunt trauma
– testicular rupture (defined as disruption of tunica albuginea) due to intense compression of testis
against inferior pubic ramus or symphysis, resulting in rupture of tunica albuginea and extrusion
of seminiferous tubules
– fracture, or "break," in testicular parenchyma
– dislocation (defined as displacement of testis out of scrotal sac) - mechanism of injury includes
spasm of the cremasteric muscle causing retraction of testis; often occurs from straddle injuries
– hematocele - develops in potential space between parietal and visceral layers of tunica vaginalis
– testicular torsion - scrotal trauma raises risk of torsion; sudden cremasteric muscle contraction
elevates and rotates testis, initiating torsion
⚬ see Etiology and Pathogenesis in Traumatic Genitourinary Tract Injuries in Adults for additional
information
● genital burns (thermal or chemical) (rare)
⚬ categories of burns as described in National Electronic Injury Surveillance System
– scalding is a burn caused by hot liquid or steam

– chemical burns are caused by acids or alkalis
– thermal burns are caused by flames or hot surfaces and formally defined as a tissue injury due to
application of heat in any form to the body surfaces; scalding burns are subset of thermal burns
– Reference - Burns 2018 Aug;44(5):1366
Other Urologic (Scrotal) Etiologies
Spermatocele (Epididymal Cyst)
● typically nonpainful masses, usually palpated in spermatic cord
● reported to be 1 of the most common adult urologic diagnoses and may be present in up to 30% of
patients
● hypothesized pathogenic mechanism includes trauma, infection, or inflammatory process
● see Spermatoceles in Benign Urologic Conditions in Men for additional information
Varicocele
● vascular lesion characterized by dilation of gonadal veins in the scrotum, sometimes described as having
a "bag of worms" appearance, and is 1 of the most common causes of scrotal swelling
● reported prevalence of varicocele
⚬ about 15% in male adults overall; up to 40% in those attending infertility clinics
⚬ 10%-20% in male adolescents (rare in children)
● etiology of varicocele includes
⚬ primary varicocele, which is due to venous reflux

⚬ secondary varicocele
– in adults
● renal cell carcinoma obstructing renal vein and, possibly, inferior vena cava
● retroperitoneal tumors or fibrosis
● portal hypertension (in patients with cirrhosis)
– in adolescents
● kidney tumors (rare)

● nutcracker effect (left renal vein compressed between descending aorta and superior
mesenteric artery; increased renal vein pressure transmitted to spermatic vein)
● see Varicocele in Adults and Varicocele in Children and Adolescents for additional information
Hydrocele
● typically painless accumulation of fluid between the parietal and visceral layers of the tunica vaginalis
and/or along the spermatic cord, leading to swelling in the scrotum or groin
● hydroceles are either communicating or noncommunicating
⚬ communicating hydroceles are caused by congenital patent processus vaginalis

⚬ noncommunicating hydroceles are acquired; causes include
– idiopathic (most common)
● thought to be caused by imbalance in fluid secretion and reabsorption within the closed sac of
the tunica vaginalis
● perhaps also due to defective lymphatic drainage impairing reabsorption of serous fluid
– reactive response to
● iatrogenic damage to lymphatic vessels during dissection of spermatic cord at time of

varicocelectomy or inguinal surgery
● infections such as
⚬ intrascrotal infection, including as acute epididymitis

⚬ regional or systemic viral disease, including mumps
⚬ lymphatic filariasis in developing countries
● abdominal trauma or torsion of the testis or testicular appendix

● malignancies such as mesothelioma and rhabdomyosarcoma
⚬ an estimated 10% of testicular tumors present with hydrocele

⚬ malignant hydrocele reported, but rare, in patients with acute lymphoblastic leukemia
● see Etiology and Pathogenesis in Hydrocele in Adults and Adolescents for additional information
Testicular Cancer
● acute scrotal pain reported to be presenting symptom in up to 20% of men with testicular cancer 2
● pain possibly related to hemorrhage within the tumor 2
● see Testicular Cancer for additional information
Idiopathic Scrotal Edema
● benign, self-limiting condition characterized by acute-onset edema and erythema involving scrotal skin
and dartos fascia 2 ,4
● perineum and inguinal region are also commonly involved; however, testes or epididymis are not
involved 2 ,4
● rarely occurs in adults; most cases are in children aged 5-8 years 2 , 4
Nonscrotal Etiologies
Inguinal Hernia
● caused by congenital or acquired weakness of the fascia transversalis (connective tissue lining abdominal
cavity) at the medial inguinal canal, allowing for protrusion of abdominal cavity contents or preperitoneal
adipose tissue through the defect
● inguinal hernias are most common type of hernias
● hernias may become incarcerated (unable to be reduced into abdominal cavity) and/or strangulated
(irreducible hernia with hernia contents showing vascular compromise)
● compression of genital branches of genitofemoral nerves upon entering spermatic cord and stretching
or tearing of tissue around hernia result in pain
● see Benign Urologic Conditions in Men and Groin Hernia in Adults and Adolescents
Kidney Colic and Ureteral Stones (Scrotal Disorder Mimic)
● kidney colic refers to flank pain associated with obstructing urinary calculi, which can radiate to the
scrotum or present as localized acute scrotal pain
● kidney colic is most common nonscrotal condition presenting with isolated acute scrotal pain
● referred scrotal pain is due to common innervation of the renal pelvis, proximal ureter, and ipsilateral
testicle as well as the distal ureter and scrotum
● References - 1 ,2 ,4 , J Ultrasound Med 2021 Mar;40(3):597
Inflammation or Infection of Nonurologic Abdominal or Pelvic Organs
● acute appendicitis and prostatitis (acute abdominal inflammation or infection)
⚬ in appendicitis, inflammation may spread to the scrotum through the patent processus vaginalis,
which allows direct communication between the abdomen and the scrotal sac
⚬ in acute prostatitis, acute scrotal pain
– is uncommon in isolation; associated symptoms include fever and chills, difficulty in urinating,
cloudy urine, and hematuria
– is due to irritation of the pelvic plexus, pudendal nerve, and autonomic and somatic nerves to the
scrotum
⚬ References - 2 , J Ultrasound Med 2021 Mar;40(3):597

⚬ see Appendicitis in Adolescents and Adults for additional information
● acute pancreatitis
⚬ rarely presents with only isolated acute scrotal pain

⚬ acute scrotal symptoms likely occur from spreading exudate, fluid collections, and necrosis of adipose
tissue along the retroperitoneum and spermatic cord, resulting in irritation of nervous pathways
innervating the scrotum
⚬ Reference - J Ultrasound Med 2021 Mar;40(3):597
⚬ see Acute Pancreatitis in Adults for additional information
● peritonitis 1
Retroperitoneal Hemorrhage
● ruptured aortic or iliac aneurysm and retroperitoneal hemorrhage
⚬ rarely, isolated acute scrotal pain is first sign of ruptured aneurysm of the aorta and common iliac
artery
⚬ pain caused by spreading of retroperitoneal hematoma into the inguinal canal with irritation of the
genital nerve and subsequent compression of the spermatic cord
⚬ References - 1 , J Ultrasound Med 2021 Mar;40(3):597
⚬ see Abdominal Aortic Aneurysm (AAA) Rupture for additional information
● other causes of spontaneous and iatrogenic retroperitoneal hemorrhage
⚬ all rarely present with acute scrotal pain

⚬ in adults, retroperitoneal hematoma may be associated with anticoagulant therapy and iatrogenic
causes
Retroperitoneal Tumors
● liposarcomas and leiomyosarcomas (most frequent malignant retroperitoneal tumors)
● lymphomas (epithelial tumors arising in retroperitoneal organs)
● metastatic lesions
● Reference - J Ultrasound Med 2021 Mar;40(3):597
Metastases From Primary Abdominal or Pelvic Neoplasms
● rare cases of advanced gastric adenocarcinoma (spreading through blood or lymphatic vessels) or with
peritoneal carcinosis presenting with acute scrotal swelling and associated pain
● acute pain related to direct localization of metastases on the spermatic cord, which stretches nerve
fibers and contracts the cremaster muscle
● Reference - J Ultrasound Med 2021 Mar;40(3):597
Other Nonscrotal Causes of Referred Scrotal Pain
● lower back strain - related to radiculitis at T10 to L1, causing nerve root irritation and referred scrotal
pain 1
● muscle injuries - injury to adductor muscles may present with acute scrotal pain (J Ultrasound Med 2021
Mar;40(3):597)
● thigh lesions - radiating pain from femoral to genital branches of genitofemoral vein (J Ultrasound Med
2021 Mar;40(3):597)
Pathogenesis
Scrotal Anatomy
● scrotum
⚬ thin fibromuscular cutaneous external sac comprised of 2 septally separated chambers

⚬ formed from fusion of labioscrotal folds
⚬ layers are a continuation of the abdominal wall and include, from superficial to deep
– skin
– dartos fascia
– external spermatic fascia
– cremasteric muscle
– internal spermatic fascia
– tunica vaginalis
● comprised of 2 layers
⚬ outer parietal layer lines internal spermatic fascia of the scrotal wall
⚬ inner visceral layer partially surrounds testicle and epididymis
● typically contains small amount of fluid (few milliliters) between its layers; however, this
potential space can fill with fluid (hydrocele), blood (hematocele), or pus (pyocele) in the setting
of disease
⚬ contains testis, epididymis, and spermatic cord
– testis
● fairly mobile within the scrotum despite anchoring to the inferior scrotum (preventing torsion)
by the scrotal ligament (also called gubernaculum)
● tunica albuginea (tough fibrous capsule) encases each testis
– epididymis
● comprised of head, body, and tail

● attached to upper testes at the head
– spermatic cord
● cordlike structure extending posteriorly from deep inguinal ring into scrotum
● houses vascular, nervous, and lymphatic tissue; provides majority of blood flow and innervation
to epididymis and testis, including
⚬ 3 arteries (provide majority of blood flow to testis and epididymis)
– testicular artery (arises from abdominal aorta) primarily supplies testis

– cremasteric artery supplies peritesticular tissues and scrotal wall
– deferential artery supplies the epididymis and vas deferens
⚬ 3 veins; venous drainage is through paired testicular veins that form the pampiniform plexus
and drain into the inferior vena cava on the right side and the left renal vein on the left side
⚬ somatic and autonomic nerves (provide majority of innervation to testis and epididymis)
– genitofemoral nerve (somatic nerve)

– spermatic nerves (autonomic nerve)
⚬ lymphatic tissue
⚬ References - 4 , Eur Radiol 2021 Jul;31(7):4918, J Ultrasound Med 2021 Mar;40(3):597
● scrotal innervation
⚬ includes somatic and autonomic nerves

⚬ somatic nerves originate from lumbar and sacral roots
– iliohypogastric nerve provides sensory innervation to skin above pubis

– ilioinguinal nerve innervates skin of inner upper portion of scrotal wall
– genitofemoral nerve innervates cremaster muscle, tunica vaginalis, anterior portion of scrotal wall,
and small area of inner thigh
– pudendal and posterior femoral cutaneous nerves innervate posterior and inferior portions of
scrotal wall
⚬ autonomic nerves
– include superior, middle, and inferior spermatic nerves

– originate from renal, intermesenteric, hypogastric, and pelvic plexuses
Pathogenesis of Acute Scrotal Pain
● ischemia and infarction due to interrupted (insufficient) blood flow; insufficient blood flow may be due to
⚬ vessel occlusion from torsion (for example, testicular torsion) or compression (such as from
hematoma or tumor)
⚬ vessel injury, infiltration, or necrosis from trauma, metastases, and infection
⚬ blood loss related to trauma
● scrotal swelling related to
⚬ infection
⚬ inflammation
⚬ extension of abdominal pathology through patent processus vaginalis
● nerve and tissue irritation; causes include
⚬ infection
⚬ inflammation
⚬ compression, dislocation, or stretching
⚬ exposure to abdominal contents (such as exudate in pancreatitis) due to patent processus vaginalis
● References - J Ultrasound Med 2021 Mar;40(3):597
History and Physical
Clinical Presentation
Overview
● acute scrotal pain requires careful history and physical examination for determination of underlying
cause 1 ,2 ,3
● many causes of acute scrotal pain have similar or overlapping features at presentation; examples include
1,2,3,4
the following
⚬ sudden onset of pain occurs in testicular torsion, Fournier gangrene, and, less often, acute
epididymitis (onset of pain is typically more gradual)
⚬ testicular or scrotal swelling occurs in testicular torsion, acute epididymitis, mumps orchitis, Fournier
gangrene, and acute idiopathic scrotal edema
⚬ palpable testicular mass occurs in testicular cancer, hydrocele, varicocele, and inguinal hernia
⚬ systemic or extratesticular features such as nausea and vomiting occur in testicular torsion and
kidney colic
● clinical presentation varies depending on cause of acute scrotal pain
Table 3: Clinical Presentation of Causes of Acute Scrotal Pain

Testicular torsion ⚬ Sudden onset ⚬ High-riding or ⚬ Previous

of severe pain horizontal episodes of
⚬ Unilateral pain testis (retracted testicular pain
and swelling upwards) ⚬ Onset at
⚬ Associated ⚬ Epididymis may waking from
nausea and be felt in sleep or during
vomiting sporting activity

⚬ Possible anterior
abdominal pain position
⚬ Absent
cremasteric
reflex
⚬ Thickened
spermatic cord
⚬ Red/blue skin
discoloration
Traumatic ⚬ Pain ⚬ Findings Recent trauma

testicular ⚬ Swelling depend on
rupture/hematoce ⚬ Ecchymosis mechanism
le ⚬ Possible and extent of
nonintact skin injury
⚬ Testicular
rupture
Acute epididymitis ⚬ Gradual onset ⚬ Focal Recent history of:

(acute epididymo- of symptoms tenderness ⚬ Urinary tract
orchitis) over 1-2 days ⚬ Pain decreases procedures
⚬ Dull, unilateral with elevation ⚬ Urinary tract
pain (Prehn sign) infection
⚬ Early, localized ⚬ Fever ⚬ Sexually
pain to ⚬ Possible transmitted
posterior testis findings: infections or
⚬ Fever – Tachypnea sexual activity
– Tachycardia ⚬ Viral illness
Symptoms of UTI
or STI:
– Hypotension
– Hematuria
⚬ Dysuria – Parotid
⚬ Frequent swelling
urination (mumps)

⚬ Urethral
discharge
Fournier gangrene ⚬ Severe pain ⚬ Fever, ⚬ Local trauma

⚬ Fever and tachycardia, ⚬ Possible
malaise tachypnea, and presence of
⚬ Worsening hypotension associated
pruritus, pain, ⚬ Subcutaneous factors such as:
and discomfort crepitus – Diabetes
over 3-5 days (hallmark of – HIV
condition) – Steroid use
⚬ Purulent disorder
drainage and – Alcohol use
patches of disorder
necrotic tissue – Malignancy
with – Lymphoproli
surrounding ferative
edema disease
⚬ Later stages of – Recent
disease: bullae instrumentat
and skin ion,
sloughing off catheterizati
⚬ On palpation, on, and
affected area is perineal
hard and trauma
wooden
⚬ Blue/purple
discoloration
and violaceous
plaques
Incarcerated Severe pain over ⚬ Unable to feel N/A

Inguinal hernia swelling/mass in spermatic cord
groin above lump

⚬ Present cough
impulse
⚬ Irreducible
Testicular cancer ⚬ Usually, ⚬ Mass/swelling Risk factor:

painless scrotal cannot be testicular
mass separated from maldescent
⚬ If pain present, the testis
may be dull ⚬ Gynecomastia
ache or heavy may be present
sensation in the
lower abdomen
Abbreviations: N/A, not applicable; STI, sexually transmitted infection; UTI, urinary tract infection.
References -
Abdom Radiol (NY) 2020 Jul;45(7):2063, J R Nav Med Serv 2016;102(1):40, BMJ 2015 Apr 2;350:h1563,
Korean J Urol 2015 Jan;56(1):3.
● features of clinical presentation that may help narrow down etiology of acute scrotal pain include 1 ,2 ,3
⚬ age at presentation
⚬ onset, duration, and quality of pain
⚬ associated signs and symptoms
⚬ medical history such as recent infection, sexually transmitted infections, and structural abnormalities
Clinical Presentation of Vascular Causes of Acute Scrotal Pain
Testicular Torsion
● important mimics include torsion of testicular appendix and acute epididymitis (acute epididymo-
orchitis) 1 , 2 , 3
● most common age at presentation is 12-18 years, with peak age between 13 and 16 years; however, it
can occur at all ages
● patients usually present with sudden onset of scrotal pain that is unrelenting 1 ,2 ,3 ,4
⚬ typically presents as severe unilateral pain, often with associated nausea and vomiting
⚬ duration of symptoms can range from several hours to several days
– about 70% of patients present within 12 hours of symptom onset
– early presentation associated with higher likelihood of salvage

⚬ can occur during night and awaken from sleep
⚬ within hours of torsion event, scrotum will start to show varying degrees of erythema, swelling, and
induration
⚬ frequently associated with lower abdominal pain
● obtain key medical history, and ask about
⚬ recent trauma (reported in up to 10%) or strenuous physical activity

⚬ history of previous episode of acute unilateral scrotal pain that resolves spontaneously within a few
hours; intermittent pain may represent episodes of torsion and detorsion
● physical exam
⚬ should include abdomen, inguinal region, penis, and scrotum; although edema and patient
discomfort can limit ability to perform physical exam
⚬ findings include
– indurated, erythematous, and warm ipsilateral scrotal skin; changes in overlying skin can progress
over time, reflecting degree of inflammation
– unilateral testicular tenderness, specifically globe of testis
– elevation (high riding) of testis, which can indicate a twisted, foreshortened spermatic cord
– transverse testicular orientation
– enlarged testis compared to unaffected side due to venous distention and transudate
– varied position of the epididymis, depending on degree of torsion
– cremasteric reflex sign considered positive if there is movement of < 0.5 cm on affected side and >
0.5 cm on unaffected side; reflex not as reliable in adults
– absence of "blue dot" sign (hallmark of torsion of testicular appendix)
– negative Prehn sign (no relief of symptoms with elevation of the scrotum)
● see History and Physical in Testicular Torsion
Torsion of Appendix Testis or Appendix Epididymis
● mimics include testicular torsion; distinguishing between these 2 types of torsions remains difficult 1 ,3 ,4
● presentation at age > 20 years is rare (typically occurs in patients aged 7-13 years) 1 , 4
● characterized by less intense, gradual onset of symptoms compared to testicular torsion, unilateral
scrotal pain and tenderness, and presence of "blue dot" sign found on upper half of hemiscrotum 1 ,2 ,4
⚬ onset of pain may be over a few days
⚬ left-side torsion occurs more frequently than right-side torsion
⚬ initially, pain is localized to the superior pole of the testis; over time, inflammation and tenderness
extend to the epididymis and testis (increasing difficulty in differentiating condition from testicular
torsion)
⚬ "blue dot" sign is highly suggestive of appendiceal torsion when present; however, less than one-third
of patients develop bluish nodule
● torsion of testicular appendix not usually associated with systemic symptoms 1
Segmental Testicular Infarction
● mimics include hypovascular testicular tumor (on ultrasound)
● occurs rarely; most reported cases are in patients aged 20-40 years
● may be associated with cardiovascular disease, sickle cell disease, polycythemia, vasculitis, epididymo-
orchitis, previous intervention, or trauma: however, most cases are idiopathic
● References - 4 , Ann Med Surg (Lond) 2020 Jul;55:265
Clinical Presentation of Infectious and Inflammatory Causes of Acute Scrotal Pain
Acute Epididymitis and Acute Epididymo-orchitis
● mimics include testicular torsion; distinguishing epididymitis from testicular torsion can be difficult 1
● most commonly occurs in patients aged 18-35 years 1 ,3
● condition characterized by gradual onset of pain and swelling (usually over 1-2 days) with or without
urethral discharge, dysuria, and systemic symptoms of fever and general malaise 1 ,2 ,3
⚬ occasionally, symptoms develop rapidly over a few hours (making distinction from testicular torsion
more challenging)
⚬ symptoms are often unilateral (left side more frequent compared to right side), starting at tail of
epididymis and spreading to adjacent testes
⚬ pain typically localized posterior to the testis but may occasionally radiate to the lower abdomen
● associated signs and symptoms may indicate 1 , 2 , 3
⚬ systemic illness, including fever, tachypnea, tachycardia, or hypotension

⚬ urinary tract infection or sexually transmitted infection (dysuria, frequency, hematuria, and urethritis)
⚬ mumps orchitis (reported to occur in about 20%-30% of patients with mumps infection); clinical
course includes fever followed by parotid swelling and, 7-10 days later, unilateral testicular swelling
⚬ tuberculosis (TB) epididymitis (painful, hard, bulky mass in acute epididymitis refractory to
conventional treatment); genitourinary TB reported in 23%-41% of those with TB
● medical history may include 1 ,2
⚬ abnormality of urinary tract

⚬ urinary tract infection or sexually transmitted infection
⚬ instrumentation of urinary tract (such as urethral catheterization or cystoscopy)
● physical findings may include 1 ,3
⚬ variable degrees of scrotal erythema and swelling

⚬ intact cremasteric reflex
⚬ relief of pain with elevation of the scrotum (Prehn sign)
⚬ painful, hard, bulky mass (characteristic of TB epididymitis, which is usually chronic)
● see History and Physical in Acute Epididymitis for additional information
Fournier Gangrene
● mimics include scrotal cellulitis, deep vein thrombosis, and myositis 4
● most often occurs in middle-aged persons 4
● chief concern
⚬ exquisite pain
– most common early feature

– precedes skin changes by 24-48 hours in vast majority
– often out of proportion to external signs
⚬ later-in-course symptoms may localize to the affected area and include
– erythema (rate of progression varies by infecting organism)

– swelling
– hemorrhage bullae
– blackish-blue discoloration of the skin
– severe, "crescendo" pain, which may indicate infarct of underlying tissue
– loss of sensation
⚬ see History and Physical in Necrotizing Fasciitis for additional information
● most common symptoms of Fournier gangrene include
⚬ scrotal pain, swelling, and erythema

⚬ systemic features such as fever, rigor, and tachycardia, which are often present
⚬ Reference - Arch Ital Urol Androl 2016 Oct 5;88(3):157
● clinical features that strongly suggest diagnosis of necrotizing fasciitis include
⚬ signs of systemic toxicity (such as fever, hypotension, leukocytosis, or acute kidney failure)
⚬ pain out of proportion to exam (often 1 of the earliest signs)
⚬ bullae or cutaneous necrosis
⚬ tense edema
⚬ gas in subcutaneous tissue
⚬ loss of sensation of affected area
⚬ rapid progression despite antimicrobial therapy
● history of present illness and medical history
⚬ ask about local trauma to identify possible port of entry
– reported in 10%-38% of patients

– lesions may be trivial or absent entirely
– portals of entry may include
● minor trauma
● soft tissue injury
● penetrating lesions, including insect or human bites
● recent surgery
● skin infection or ulcers
● injection sites and injection drug use
⚬ ask about recent exposures to causative pathogens; for example, consider
– group A Streptococcus if patient has history of tonsillitis, skin trauma, close contact with impetigo,
or recent varicella zoster virus infection
– water-borne pathogens if patient has
● exposure to seawateror handled or consumed raw seafood (Vibrio spp.)

● exposure to fresh or brackish water (Aeromonas spp.)
– zygomycetes, such as Mucor or Rhizopus spp., with soil exposure

– unusual organisms in patients with recent foreign travel
⚬ tempo of illness may also suggest causative pathogen(s)
– polymicrobial necrotizing fasciitis may evolve over days

– monomicrobial necrotizing fasciitis progresses far more rapidly
● past medical history - consider history of immune compromise, including
⚬ diabetes mellitus
⚬ chronic corticosteroid misuse and cytotoxic drugs
⚬ alcohol misuse
⚬ HIV
⚬ lymphoproliferative diseases
⚬ malnutrition
⚬ lower socioeconomic status
⚬ Reference - Arch Ital Urol Androl 2016 Oct 5;88(3):157
● physical
⚬ signs of systemic toxicity may be profound and precede skin findings (including fever, tachycardia,
hypotension, and delirium)
⚬ skin
– examination of local site may reveal
● cutaneous inflammation
● edema
● purple/blue discoloration and violaceous plaques indicating underlying necrosis
● bullae and skin sloughing in later stages
● anesthesia
– palpation of involved subcutaneous tissue may reveal
● a hard, wooden feeling with loss of distinction between fascial planes and muscle (unlike
cellulitis wherein subcutaneous tissues are palpable and yielding)
● crepitus (sensation of crackling or popping), which may indicate subcutaneous gas and
presence of gas-forming organisms in tissue
Henoch-Schonlein Purpura
● mimics include testicular torsion and incarcerated inguinal hernia (both of which require prompt or
urgent surgical intervention) 1
● typically affects patients < 20 years old (can occur at any age, but 90% of cases reported in children < 10
1
years old)
● common presentation is acute or subacute onset of disease with palpable purpura involving the lower
extremities without associated thrombocytopenia or coagulopathy; other common features include
⚬ abdominal pain
⚬ arthralgia or arthritis, often involving knees and ankles
⚬ kidney dysfunction
⚬ see History and Physical in Henoch-Schonlein Purpura for additional information
● scrotal involvement reported in 2%-38% of patients and may include marked edema of scrotal skin and
contents, epididymal enlargement, and hydrocele 1
Behcet Syndrome
● acute scrotal pain reported in 4%-31% of patients with Behcet syndrome (Ann Med Surg (Lond) 2020
Jul;55:265)
● clinical presentation
⚬ classic symptom complex includes oral aphthous and genital ulcers, ocular lesions, and skin lesions,
with recurrent oral aphthous ulcers reported to occur in almost all patients
⚬ genital ulcers reported in 60%-90% of patients
– can occur anywhere in genitourinary tract but most commonly occur on scrotum in men and vulva
in women
– may be disseminated and painful, or indolent
⚬ see History and Physical in Behcet Syndrome for additional information
Polyarteritis Nodosa
● presentation of polyarteritis nodosa
⚬ severity of disease varies; patients may present with either indolent or acute symptoms, and it may be
localized, generalized, or severe and life-threatening
⚬ common symptoms include fever, weight loss, myalgia, arthralgia, malaise, and peripheral
neuropathy
⚬ see History and Physical in Polyarteritis Nodosa for additional information
● testicular pain/tenderness reported in 2%-8% of patients with polyarteritis nodosa (Ann Med Surg (Lond)
2020 Jul;55:265)
● reported cases of testicular involvement with and without systemic involvement (J Med Case Rep 2019 Jul
31;13(1):236)
Clinical Presentation of Trauma-related Causes of Acute Scrotal Pain
Traumatic Testicular Rupture
● mimics include hydrocele
● clinical presentation may include
⚬ immediate pain, nausea, vomiting, and possibly fainting

⚬ tender, swollen, and ecchymotic hemiscrotum
⚬ testes that are difficult to palpate
● medical and social history may include
⚬ blunt trauma from sports-related injuries or injuries from motor vehicle or bicycle accidents
⚬ penetrating trauma typically due to firearm
● see History and Physical in Traumatic Genitourinary Tract Injuries in Adults for additional information
Other Trauma-related Causes
● trauma-related causes (other than traumatic testicular rupture) include
⚬ testicular fractures
⚬ traumatic testicular torsion
⚬ testicular dislocation
⚬ hematoma (intratesticular, extratesticular)
⚬ trauma-related hydrocele
⚬ traumatic epididymitis
● clinical presentation includes
⚬ immediate pain and swelling of scrotum, usually right testis

⚬ associated nausea and vomiting
⚬ occasionally, presentation with only mild discomfort
● medical history may include motor vehicle accident, sports injury, bite, burn, combat, or previous
genitourinary surgery or procedure
● similar to testicular rupture, physical findings may include
⚬ swelling
⚬ hematoma
⚬ palpable deformity
⚬ abnormal testicular lie
⚬ skin manifestations such as erythema, blisters, and loss of skin
⚬ injures to other adjacent structures (penis and perineum)
⚬ absent cremasteric reflex
● see History and Physical in Traumatic Genitourinary Tract Injuries in Adults for additional information
Clinical Presentation of Other Urologic or Scrotal Causes of Acute Scrotal Pain
Spermatocele (Epididymal Cyst)
● clinical presentation typically includes
⚬ nonpainful mass
⚬ incidental discovery by patient or during routine physical exam
⚬ location within scrotum (cephalic or posterior to testis), though it may be found anywhere on
epididymis
⚬ distinct borders and easy separation from testis on palpation
⚬ see Spermatoceles in Benign Urologic Conditions in Men
● pain reported in about 70% of 24 male adults seeking spermatocelectomy in retrospective cohort study
(Arch Androl 2007 Nov-Dec;53(6):345)
Varicocele
● clinical presentation
⚬ usually asymptomatic (incidental finding on physical exam)

⚬ when symptomatic (reported in 5%-10% of cases), scrotal pain may present with heaviness or dull
ache, which may be exacerbated by prolonged standing or running and relieved by lying supine
⚬ scrotum may have a "bag of worms" appearance or consistency and typically decompresses and
disappears when patient is supine
⚬ varicocele commonly appears during the testicular growth spurt in early puberty, with a notable spike
in clinical presentation at about age 13 years
⚬ most cases reportedly present only on the left side
– approximately 85%-90% are left-sided, unilateral

– approximately 10% are bilateral
– < 5% are right-sided, unilateral (usually secondary varicocele)
⚬ ask about history of first-degree relatives with varicocele

⚬ see History and Physical in Varicocele in Adults and Varicocele in Children and Adolescents
● medical history may include
⚬ first-degree relative with varicocele

⚬ gross hematuria
⚬ flank pain
⚬ history of alcohol misuse (may suggest portal hypertension due to cirrhosis)
⚬ hepatitis B or C infection (may suggest portal hypertension due to cirrhosis)
⚬ see History and Physical in Varicocele in Adults and Varicocele in Children and Adolescents
Hydrocele
● clinical presentation includes 2 ,3
⚬ typically painless lump; however, discomfort or heaviness may occur

⚬ possible enlargement of size of swelling from standing
⚬ ache in scrotum or back may indicate larger hydrocele
⚬ neck of spermatic cord may be palpable above swelling
● medical history may include 3
⚬ injury (including torsion)

⚬ infection
⚬ tumors and radiotherapy
⚬ conditions causing generalized edema (nephrotic syndrome or heart failure)
● physical findings may include
⚬ swelling
⚬ in patients from endemic regions (> 70 countries in tropical and subtropical parts of Asia, Africa, the
Western Pacific, South America, and the Caribbean), presence of nodular spermatic cord or
lymphangiectasia-indicated filariasis
⚬ on transillumination of hemiscrotum with penlight or otoscope, findings may include
– tense, smooth, scrotal mass that easily transilluminates (confirms diagnosis of hydrocele)
– thickened tunica vaginalis that will not transilluminate; ultrasound may be needed
⚬ in adolescents, to differentiate communicating hydrocele from noncommunicating hydrocele
– usual finding with communicating hydrocele is fluctuant mass that may be reducible with manual
pressure
– noncommunicating hydrocele is fluctuant mass that is not reducible with manual pressure
– hydrocele in persistent processus vaginalis can be palpated above the testis along the spermatic
cord
– 86% of hydroceles in adolescents > 12 years old were noncommunicating in retrospective case
series of 93 patients (age range 0.1-20 years) who had surgical repair of 101 hydroceles
⚬ if large, tense hydrocele is present, adequate palpation of the testis may be difficult and ultrasound is
recommended to rule out solid testicular mass
⚬ see History and Physical in Hydrocele in Adults and Adolescents and Epidemiology in Lymphatic
Filariasis
Testicular Cancer
● mimics include evolving varicocele, hydrocele, or focal hematomas 4
● clinical presentation includes
⚬ unilateral scrotal pain and swelling or mass 1 , 2
– pain reported to be a presenting feature in about 20% of patients with testicular cancer
– suggested causes of scrotal pain include rapidly growing testicular mass, especially if accompanied
by internal bleeding or areas of infarction
⚬ dull or heavy sensation in scrotum or lower abdomen 3
⚬ manifestations of metastases, such as
– back pain
– cough
– hemoptysis
– headaches
– Reference - N Engl J Med 2014 Nov 20;371(21):2005
● medical history may include minor trauma or testicular maldescent 3
● physical findings may include 3
⚬ unilateral swelling or nodule (cannot be palpated separately from testis)

⚬ gynecomastia
⚬ reactive hydrocele that may be seen when the scrotum is transilluminated
● see Testicular Cancer for additional information
Clinical Presentation of Nonscrotal Causes
Incarcerated or Strangulated Inguinal Hernia
● mimics include scrotal lump such as hydrocele or scrotal abscess 3
● inguinal hernias are at risk for incarceration (cannot be reduced into abdominal cavity) and strangulation
(compromised blood supply and lymphatic drainage), resulting in ischemia and possible necrosis;
strangulated hernias reported to occur in up to 5% of cases 3
● clinical presentation includes 2 ,3
⚬ incarcerated hernia presenting with severe pain over a swelling in the groin or scrotum
⚬ abdominal pain and vomiting, which may occur if a hernia contains the small bowel
⚬ lump in the groin that can descend into the scrotum through the inguinal canal
● physical finding may include 3
⚬ inability to feel the neck (or spermatic cord) above the scrotal mass, which indicates a hernia arising
from the abdomen and extending down along the inguinal canal
⚬ ability to feel the neck above the scrotal mass, which indicates the mass is arising from the scrotum
(for example, hydrocele)
⚬ strong cough impulse or expansion of mass
● see History and Physical in Groin Hernia in Adults and Adolescents for more information
Kidney Colic and Ureteral Stones
● may be asymptomatic
● typical symptoms of acute kidney colic
⚬ flank pain that may radiate to the lower abdomen or groin

⚬ pain often described as colicky and intermittent
⚬ often associated with nausea and vomiting
● additional symptoms of ureteral calculi include
⚬ dysuria
⚬ urgency and frequency
⚬ possible fever and chills with obstructing calculi (due to urinary infection causing or resulting from a
stone)
⚬ scrotal, labial, penile, or pelvic pain
● see History and Physical in Nephrolithiasis in Adults
Other Nonscrotal Causes
● ruptured abdominal aortic aneurysm and retroperitoneal hemorrhage
⚬ presentation of isolated acute scrotal pain without local changes in the scrotum has been reported as
the first clinical sign of a ruptured aortic aneurysm (J Ultrasound Med 2021 Mar;40(3):597)
⚬ see History and Physical in Abdominal Aortic Aneurysm (AAA) Rupture for additional information
● acute appendicitis
⚬ typically associated with abdominal pain that localizes to the right iliac fossa 2
⚬ see Appendicitis in Adolescents and Adults for additional information
⚬ rarely presents with only isolated acute scrotal pain (J Ultrasound Med 2021 Mar;40(3):597)
⚬ see Acute Pancreatitis in Adults for additional information
History
History of Present Illness
● patient age and history provide important clues to help identify cause of acute scrotal pain 1 , 2 , 3 , 4
● ask about
⚬ age at onset of symptoms; although age of onset may help narrow causes of acute scrotal pain, it
does not exclude any cause 2
⚬ pain characteristics, including 1 ,2 ,3 ,4
– onset and duration

– severity and quality of pain (dull, aching, or throbbing)
– anatomic location (unilateral or bilateral) and any changes (localized pain becoming diffuse or
radiating to other areas)
– associated symptoms such as swelling, erythema, or edema
– factors that alleviate or worsen pain (for example, elevation may decrease pain in some conditions)
● ask about associated symptoms such as 2 , 3
⚬ nausea and vomiting

⚬ fever
⚬ symptoms of urinary tract infection, including dysuria and frequency
⚬ symptoms of sexually transmitted infection, including dysuria or urethral discharge
⚬ recent catheterization or instrumentation of urinary tract
⚬ parotid swelling
Medication History
● ask about medications, including
⚬ amiodarone 1
⚬ anticoagulants - may contribute to bleeding development of retroperitoneal hematoma (presenting as

acute scrotal pain) (J Ultrasound Med 2021 Mar;40(3):597)
⚬ drugs associated with Henoch-Schonlein purpura in adults; ask about recent exposure to
– angiotensin-converting enzyme inhibitors

– angiotensin II receptor antagonists
– antibiotics
– nonsteroidal anti-inflammatory drugs
– influenza vaccination
– Reference - Int J Dermatol 2009 Nov;48(11):1157
Past Medical History (PMH)
● ask about history of 1 ,2 ,3 ,4
⚬ testicular torsion
⚬ urinary tract abnormality
⚬ urinary tract infections
⚬ sexually transmitted infections and sexual history
⚬ recent trauma
⚬ history of testicular maldescent
⚬ instrumentation of the urinary tract, such as urethral catheterization or cystoscopy (risk factor for
urinary tract infections and secondary epididymo-orchitis)
Family History (FH)
● ask about first-degree relatives with varicocele (Asian J Androl 2016 Mar-Apr;18(2):179)
Physical
Approach to Physical Exam
● immediately assess for any cause of acute scrotal pain requiring emergent or urgent care 1 , 2 , 3 , 4
● assess general appearance of patient for
⚬ level of discomfort 2
⚬ early signs of distress or sepsis 2
● perform abdominal exam followed by genitourinary exam 2
Abdominal and Genitourinary Exam
● abdominal exam
⚬ assess for 2
– signs of hernia; if hernia suspected, patient is best examined while lying and standing and cough
impulse should be checked
– signs of lower or upper urinary tract infection, such as suprapubic tenderness and presence of
costovertebral tenderness
– flank tenderness (sign of kidney colic or ureteric colic that can result in referred pain to the
scrotum)
– signs of appendicitis
– palpable bladder (suggests distention)
● genitourinary exam
⚬ performing a complete examination on an adult or adolescent with acute scrotal pain may be difficult
due to severity of pain, dependent nature of the scrotum, edema, and changes in skin; patient factors
and history associated with pain are essential to direct diagnostic steps 1
⚬ examine groin for 2
– hernias
– other masses or swelling
– skin changes such as cellulitis
⚬ assess scrotum for 1 ,2 ,3
– position of testes within the scrotum, including elevation of 1 testis (high-riding) or abnormal
position of 1 testis (for example, transverse testicular orientation as may be found in testicular
torsion) compared to contralateral testis
– tenderness
– size and symmetry of testes
– changes in overlying skin, such as erythema and cellulitis
– lumps or masses; if present, note degree of swelling, location, and consistency (smooth or rough
surface)
– presence of cremasteric reflex
● elicited by lightly stroking or pinching medial thigh on side of suspected torsion

● contraction of cremasteric muscles results in elevation of testis; sign considered positive if there
is movement of < 0.5 cm on affected side and > 0.5 cm on unaffected side
● reported 100% sensitivity and 66% specificity for testicular torsion
– presence of "blue dot" sign

– site of maximal tenderness
● testes
● epididymis
● upper pole of testes
Diagnostic Testing
Testing Overview
● acute scrotal pain requires careful history and physical examination for determination of underlying
1,2,3
cause
● prompt diagnosis of underlying cause is necessary to rule out causes that represent a medical
emergency and require immediate treatment, such as testicular torsion
● diagnostic approach may vary based on suspected cause, including
⚬ vascular disruption such as testicular torsion, torsion of testicular appendage, or segmental testicular
infarction
⚬ infection or inflammation such as acute epididymitis, Fournier gangrene, Henoch-Schonlein purpura,
Behcet syndrome, or polyarteritis nodosa
⚬ trauma
⚬ other urologic or scrotal causes such as testicular cancer, hydrocele, varicocele, or spermatocele
⚬ nonscrotal causes such as incarcerated or strangulated hernia or kidney colic
● diagnostic approaches may include blood tests, urine studies, and imaging studies
Initial Approach
● prompt diagnosis of underlying cause is necessary to rule out causes that represent a medical
emergency and require immediate treatment; in particular, testicular torsion should be considered for
patients presenting with acute scrotal pain since prompt assessment and treatment are essential to
preserve testicular function 2 ,3 ,4
● first step is to confirm or rule out testicular torsion (due to short time to salvage testicular function)
⚬ suspect testicular torsion
– in adults and adolescents with 1 , 2 , 3 , 4
● sudden-onset, severe, unilateral testicular pain, which is often associated with nausea and
vomiting
● elevated ("high-riding") swollen and tender testis
● absence of ipsilateral cremasteric reflex
– immediate surgical and urology consult indicated 1 ,2 ,3 ,4
● if testicular torsion is not suspected or is ruled out, consider alternative etiologies including
⚬ acute epididymitis
– suspect in adults and adolescents with clinical presentation that includes 1 ,2 ,3 ,4
● gradually increasing, dull, unilateral scrotal pain and swelling; however, sudden onset may
occur
● possible fever, urethral discharge, dysuria, and/or swollen parotid glands
● possible history of urinary tract infection, sexual activity, instrumentation of urinary tract, or
nonspecific viral illness
● positive Prehn sign (alleviation of pain with elevation of scrotum) and intact cremasteric reflex
– investigations include 1 , 2 , 3
● urine studies and blood tests to detect infection and causative pathogen
⚬ urinalysis/urine dipstick to detect presence of infection

⚬ midstream urine specimen for microscopy, culture, and sensitivity
⚬ if suspected sexually transmitted infection, urethral swabs for culture and nucleic acid
amplification for Neisseria gonorrhoeae and Chlamydia trachomatis
⚬ IgG and IgM if mumps suspected
● color Doppler ultrasound, which may be useful to
⚬ rule out testicular torsion

⚬ help confirm diagnosis; supportive findings include
– normal or increased blood flow to affected testis (reduced or absent blood flow with
testicular torsion)
– enlarged testis, abscess formation, or hydrocele
⚬ Fournier gangrene
– suspect in male adults (mean age 50-60 years) with clinical presentation that includes
● severe pain, swelling, and erythema with or without fever and malaise
● subcutaneous crepitus on exam (characteristic manifestation), patches of gangrene, and
purulent discharge
– investigations include assessment to evaluate clinical status and causative pathogen(s), including
● blood tests such as complete blood count, biochemistry panel, and arterial blood gas
● blood sample for microbiology, culture, and sensitivity to identify pathogen (anaerobic and
aerobic pathogens involved)
● imaging (only if needed for diagnosis), which should not delay treatment
– urgent surgical debridement and prompt broad-spectrum IV antibiotics indicated based on clinical
diagnosis
– References - 4 , Arch Ital Urol Androl 2016 Oct 5;88(3):157
⚬ trauma-related scrotal injury - suspect in young adults and adolescents with clinical presentation
consistent with trauma (including mechanism of injury)
– if blunt scrotal trauma, investigate extent and severity with scrotal ultrasound; if findings are
consistent with
● testicular rupture, exploratory surgery indicated
● other traumatic testicular injury, treat as appropriate
– if penetrating scrotal trauma, exploratory surgery indicated
⚬ incarcerated or strangulated hernia
– suspect in adults and adolescents with clinical presentation that includes 2 , 3
● severe pain over a swelling in groin or scrotum

● abdominal pain and vomiting if a hernia includes small bowel
● irreducible hernia on exam
– clinical diagnosis with urgent surgical intervention indicated 3
⚬ testicular cancer
– suspect in adults and adolescents with clinical presentation that includes 1 ,2
● painless or painful scrotal mass (dull ache or heavy sensation); possible gynecomastia or lower
back strain
● history of testicular maldescent
● on palpation, swelling/mass that cannot be separated from the testis; negative
transillumination of mass
– prompt referral to urology indicated for further work-up, which likely includes 3 , 4
● imaging, such as ultrasound and computed tomography

● blood tests, including tumor markers
● biopsy
Table 4: Summary of Findings on Diagnostic Testing of Causes of Acute Scrotal Pain

Testing r Doppler

Testing r Doppler
Testicular torsion ⚬ Clinical Normal urinalysis ⚬ Early finding:

diagnosis (does not exclude decreased or
⚬ Confirmed with diagnosis) absent venous
surgery or blood flow
ultrasound ⚬ Later finding:
decreased or
absent arterial
flow
⚬ Testicular
enlargement,
heterogeneity,
and
hypoechogenici
ty representing
edema
⚬ Twisting of
spermatic cord,
scrotal skin
thickening, and
secondary
hydrocele may
also be seen
Traumatic ⚬ For blunt Possible ⚬ Heterogeneous

testicular trauma: hematuria on -appearing
rupture/hematoce ultrasound urinalysis with testis with
le ⚬ For penetrating polytrauma discontinuity of
trauma: surrounding
exploratory tunica
surgery albuginea
⚬ Indistinct
testicular
margins

Testing r Doppler
⚬ Loss of
vascularity to
part of or
entire affected
testis
⚬ Hematocele
usually present
⚬ Testes may be
fragmented
Acute epididymitis ⚬ Diagnosis May have positive ⚬ Performed to

(acute epididymo- based on findings on: rule out
orchitis) clinical and ⚬ Urinalysis testicular
laboratory (indicating UTI) torsion
findings ⚬ Urine cultures ⚬ Increased
⚬ Urinalysis ⚬ Urethral blood flow to
⚬ Midstream cultures testes and/or
catch for ⚬ Blood cultures epididymis
microscopy and ⚬ Enlarged,
culture hypoechoic
⚬ Urethral culture epididymis
⚬ Immunoglobuli ⚬ Reactive
n levels (if hydrocele
mumps ⚬ Scrotal wall
suspected) thickening
⚬ Color Doppler
ultrasound
Fournier gangrene ⚬ Diagnosis ⚬ Leukocytosis or Findings include:

confirmed at leukopenia ⚬ Diffuse
surgery ⚬ Evidence of subcutaneous
⚬ Blood tests hemolysis such tissue
including CBC, as falling thickening
coagulation hemoglobin

Testing r Doppler
studies, with stable ⚬ Perifascial fluid

metabolic hematocrit accumulation
panel, LFTs, ⚬ Hematocrit < ⚬ Bright
lactate, CRP, 20% or > 60% echogenic foci
creatinine ⚬ Thrombocytope with dirty
kinase, arterial nia shadowing
blood gas ⚬ Acute kidney ⚬ Reverberation
⚬ Blood cultures failure artifacts
⚬ Baseline ⚬ Hypocalcemia corresponding
immunoglobuli ⚬ Hyponatremia to underlying
n levels ⚬ Hypokalemia soft tissue gas
⚬ Computed ⚬ Hypomagnese
tomography mia
⚬ Low albumin
⚬ Elevated
glucose
⚬ Elevated serum
lactate
⚬ Metabolic
acidosis
⚬ Elevated CRP
⚬ Elevated
creatinine
kinase
⚬ see Diagnosis
in Necrotizing
Fasciitis
Incarcerated ⚬ Clinical N/A ⚬ Sonographic

inguinal hernia diagnosis appearance
⚬ Ultrasound if depends on
diagnosis hernial sac
unclear contents

Testing r Doppler
⚬ Most
commonly
contains bowel,
followed by
omentum
⚬ Grayscale
findings show
fluid- or air-
filled loop of
bowel in the
scrotum
⚬ Bowel
strangulation
appears as
akinetic dilated
loops of bowel
⚬ Hyperemia of
scrotal soft
tissue and
bowel wall
suggests
strangulation
Testicular cancer ⚬ Diagnosis ⚬ May have Well-defined,

confirmed by positive tumor hypoechoic or
histology markers: heterogeneous
⚬ Testicular echogenic
– Beta-hCG
ultrasound – LDH intratesticular
⚬ Blood tests lesions
– AFP
including CBC,
⚬ See Diagnosis
electrolytes and
and Staging in
creatinine,
Testicular Cancer
LFTs, and
serum tumor

Testing r Doppler
markers (beta-
hCG, LDH, and
AFP)
⚬ Biopsy
Abbreviations: AFP, alpha fetoprotein; Beta-hCG, beta-human chorionic gonadotropin; CBC,

complete blood count; CRP, C-reactive protein; LDH, lactate dehydrogenase; LFTs, liver function
tests; N/A, not applicable; UTI, urinary tract infection.
References -
Radiol Clin North Am 2004 Mar;42(2):349, Abdom Radiol (NY) 2020 Jul;45(7):2063, J R Nav Med Serv
2016;102(1):40, BMJ 2015 Apr 2;350:h1563, Korean J Urol 2015 Jan;56(1):3, American Urological
Association (AUA) Urotrauma Guideline 2020 Aug , Arch Ital Urol Androl 2016 Oct 5;88(3):157.
● approach in adults and adolescents with other suspected etiologies
⚬ scrotal pain in the setting of suspected vascular disruption or ischemia
– such as torsion of testicular appendix or segmental testicular infarction

– investigation includes ultrasound (color Doppler ultrasound)
⚬ scrotal pain (testicular vasculitis) in the setting of suspected systemic condition (systemic vasculitis) or
disease
– such as Henoch-Schonlein purpura, Behcet syndrome, and polyarteritis nodosa
– investigations, such as laboratory investigations, directed by suspected cause
1
– References - , Ann Med Surg (Lond) 2020 Jul;55:265
⚬ other scrotal-related causes
– scrotal or testicular masses 3 ,4
● hydrocele
● varicocele
● spermatocele (epididymal cyst)
● testicular tumors
– investigations include ultrasound and transillumination 1 ,3 ,4
⚬ nonscrotal-related causes
– suspect nonscrotal cause in patients with normal scrotal exam

– isolated scrotal pain may be first symptom in serious conditions such as
● kidney colic
● inguinal hernia
● abdominal aortic aneurysm rupture

● retroperitoneal hemorrhage
● retroperitoneal tumors
● acute appendicitis
● peritonitis
– investigations should include abdominal assessments
– References - 1 ,2 ,4 , J Ultrasound Med 2021 Mar;40(3):597
Approach Based on Suspected Vascular Disruption (Ischemia)
● testicular torsion
⚬ primarily a clinical diagnosis based on history and physical exam

⚬ if testicular torsion suspected
– ultrasound and surgical consultation should be immediately obtained
● Doppler ultrasound recommended to evaluate for testicular torsion without delaying surgical
exploration
⚬ torsion characterized by decreased or absent blood flow
⚬ Doppler ultrasound preferred over radionuclide imaging
● relative decrease or absent arterial blood flow within suspected testis on color-flow Doppler
ultrasound is indicative of testicular torsion
● typically a 4- to 8-hour window before permanent ischemic damage occurs
● diagnosis confirmed at time of surgical exploration
– consider urinalysis if epididymitis suspected; however, with testicular torsion, urinalysis is often
normal, and an abnormal urinalysis does not exclude testicular torsion
– other tests warranted only if helpful to exclude other causes of acute scrotum
⚬ see Diagnosis in Testicular Torsion for additional information
● torsion of testicular appendage (appendix testis or appendix epididymis) 1 , 4
⚬ ultrasound may be useful to diagnose and differentiate torsion of testicular appendage from
testicular torsion
⚬ findings on ultrasound include
– torsed appendages that appear as enlarged, rounded, extratesticular masses, with mixed
hyperechoic and heterogenous echotexture depending on degree of ischemia
– absent flow on color Doppler imaging and hyperemia of surrounding structures; secondary
findings include enlarged epididymal head, reactive hydrocele, and scrotal skin thickening
● segmental testicular infarction
⚬ use of ultrasound may help in diagnosis; findings supporting diagnosis include 4
– geographic or wedge-shaped hypoechoic abnormality that is avascular or hypovascular on color

Doppler
– possible peripheral hyperemic rim
⚬ contrast-enhanced ultrasound and magnetic resonance imaging may also be used for equivocal
findings on conventional ultrasound 4
Approach Based on Suspected Infection or Inflammation
● acute epididymitis
⚬ diagnosis of acute epididymitis typically made based on compatible physical exam findings and
confirmed by laboratory testing
– suspect diagnosis in patients with tender epididymis on physical examination; supportive clinical
features include
● gradual onset of pain
● localization of pain posterior to testis, with occasional radiation to lower abdomen
● concurrent symptoms of urethritis or urinary tract infection
– evaluate all suspected cases for evidence of inflammation, which can be determined by any of the
following
● Gram stain or methylene blue stain of urethral swab showing ≥ 2 white blood cells (WBC) per oil
immersion field
● positive leukocyte esterase on urinalysis
● urine microscopy with ≥ 10 WBC per high-power field
– to determine cause
● test patients at high risk for sexually transmitted infections (STIs) for Chlamydia trachomatis and
Neisseria gonorrhoeae by nucleic acid amplification testing (urine is preferred specimen)
● urine culture in all children and adults with positive urinalysis or potential STI
● urine culture in patients with infection likely due to enteric pathogens
⚬ test all patients with relevant sexual histories for other STIs
⚬ consider scrotal ultrasound when diagnosis is unclear clinically and to help rule out testicular torsion
– color Doppler ultrasound findings associated with epididymitis include
● hyperemia
● swelling
● increased blood flow
⚬ urology referral and additional testing, such as biopsy, may be needed for immunocompromised
patients and those who do not respond to initial therapy
⚬ see Acute Epididymitis for additional information
● Fournier gangrene (type of necrotizing fasciitis)
⚬ necrotizing fasciitis is a surgical emergency, and prompt diagnosis is imperative

⚬ clinical features that strongly suggest diagnosis of necrotizing fasciitis include
– signs of systemic toxicity (such as fever, hypotension, leukocytosis, or acute renal failure)
– pain out of proportion to exam (often 1 of the earliest signs)
– bullae or cutaneous necrosis
– tense edema
– gas in subcutaneous tissue
loss of sensation of affected area
–
– rapid progression despite antimicrobial therapy
⚬ many of these signs occur late in disease, and clinical judgment is critical to diagnosis
⚬ when diagnosis is strongly suspected on clinical grounds, emergent surgical exploration is needed
⚬ definitive diagnosis can be made only by surgical exploration of affected area
⚬ Gram stain of exudate may be performed to aid in rapid identification of causative organism
⚬ microbiologic diagnosis requires culture of organism from affected tissue or blood
⚬ when necrotizing fasciitis suspected, obtaining blood tests or imaging should not delay surgery
⚬ see Diagnosis in Necrotizing Fasciitis for additional information
⚬ diagnosis is often clinical (no diagnostic laboratory test is available)

⚬ if suspected, consider laboratory testing to determine renal involvement and exclude other
diagnoses, including
– urinalysis
– complete blood count and coagulation profile
– chemistry panel including electrolytes, blood urea nitrogen, and creatinine
– blood cultures to assess for bacteremia or sepsis
– blood tests to identify previous streptococcal infection
– autoantibody testing to rule out other vasculitides or autoimmune disorders
⚬ consider imaging studies (depending on manifestations) or a biopsy of the skin or kidney to help
diagnosis or guide therapy in atypical or severe cases
⚬ diagnoses based on criteria recommended by professional organizations
⚬ see Diagnosis in Henoch-Schonlein Purpura for additional information
● Behcet syndrome
⚬ diagnosis based on clinical findings, but multiple sets of diagnostic criteria have been proposed with
no universally agreed on criteria
⚬ no test findings are specific for Behcet syndrome
⚬ laboratory studies may be most useful for ruling out other causes of clinical manifestations
⚬ see Diagnosis in Behcet Syndrome for additional information
⚬ for suspected polyarteritis nodosa, testing includes
– biopsy performed at affected site to detect inflammation of medium arteries

– angiography, which may be used to detect microaneurysms when histologic diagnosis cannot be
obtained
– blood tests, which may identify causes of vasculitis as well as complications from organ
involvement, such as antineutrophil cytoplasmic antibody, complete blood count, and renal and
liver function tests
⚬ definitive diagnosis based on signs and symptoms of vasculitis, vascular inflammation of small or
medium-sized arteries on biopsy, and specific indirect evidence of vasculitis
⚬ see Diagnosis in Polyarteritis Nodosa for additional information
Approach Based on Suspected Trauma
● investigations include imaging, mainly ultrasound, to help determine extent and severity of trauma-
related injury and help detect injuries requiring surgery, such as testicular rupture 4
● initial testing includes
⚬ for suspected blunt testicular injury
– ultrasound
● scrotal ultrasonography is first-line imaging for blunt scrotal trauma

● useful for detection of testicular hematoma, rupture, dislocation to inguinal canal, or torsion
● limited utility for diagnosis of testicular rupture in the setting of penetrating scrotal trauma
– may include Doppler duplex ultrasound for assessment of perfusion
⚬ for suspected penetrating scrotal injury, prompt surgical exploration is recommended over
ultrasound due to high rate of testicular injury and limited utility of ultrasound in this setting
⚬ urine assessments to assess for hematuria
● if initial testing is inconclusive, additional testing and/or procedures may include
⚬ computed tomography scan

⚬ magnetic resonance imaging
⚬ surgical exploration if testicular rupture suspected
● for ultrasound findings for specific traumatic testicular injuries, see Diagnosis in Traumatic Genitourinary
Tract Injuries in Adults
● findings on imaging for other traumatic testicular injuries
⚬ for suspected testicular fracture, findings include
– presence of linear hypoechoic, avascular area within the testicular parenchyma that may or may
not be associated with tunica albuginea rupture
– Doppler ultrasound used to evaluate flow within testicular parenchyma and measure of
salvageability
⚬ for testicular dislocation
– difficult to diagnose with ultrasound after acute trauma

– color-flow Doppler ultrasound used to assess viability of dislocated testis
⚬ for testicular hematoma, findings may include
– hyperacute and acute hematomas that may appear isoechoic to normal testicular parenchyma and
are difficult to diagnose
– may be detected more easily on follow-up imaging; acute hematomas may be reexamined within
12-24 hours for changes in echogenicity
– as hematomas evolve, become more hypoechoic or anechoic, and eventually decrease in size,
Doppler may be used to differentiate evolving hematomas from tumor
⚬ for scrotal hematoma or hematocele, findings may include
– extratesticular hematoceles, or collections of blood within the tunica, which are common findings
after blunt trauma
– ultrasound appearance depends on age of lesion; acute hematocele is echogenic, and chronic
hematocele is more anechoic
⚬ for traumatic epididymitis, findings may include
– on ultrasound, enlarged heterogeneous epididymal head that is hypoechoic compared to the testis
due swelling and edema
– on color Doppler imaging, increased flow to epididymal head
– heterogeneity of epididymal head, which may be due to hematoma or contusion but may appear
similar to infectious epididymitis (more common); history of injury may indicate traumatic
epididymitis
⚬ see Diagnosis in Traumatic Genitourinary Tract Injuries in Adults
Approach Based on Other Suspected Urologic or Scrotal Causes
● testicular cancer
⚬ general diagnostic approach may include
– imaging such as testicular ultrasound

– blood tests such as
● complete blood count

● electrolytes and creatinine
● liver function tests
● serum tumor markers including beta-human chorionic gonadotropin, lactate dehydrogenase,
and alpha fetoprotein
– biopsy
– see Diagnosis and Staging in Testicular Cancer for additional information on postdiagnostic
evaluation
● hydrocele
⚬ clinical diagnosis based on palpation of painless, tense, fluid-filled swelling in scrotum or groin that
easily transilluminates, typically with a history of the mass having enlarged gradually over time
⚬ ultrasound may be required to confirm diagnosis if palpation and transillumination are inconclusive
⚬ see Diagnosis in Hydrocele in Adults and Adolescents
● varicocele
⚬ diagnosis based on physical exam (standard of care for diagnosing varicocele)
– inspection and palpation of scrotum in standing and supine positions with and without a Valsalva
maneuver in a warm room to facilitate relaxation of the cremasteric and dartos muscle fibers of
the scrotum
– varicocele graded based on ability to visualize and palpate the dilated spermatic cord veins while
relaxed and while inducing Valsalva
– isolated right-sided varicocele, sudden onset, age > 40 years, or varicocele that is irreducible in the
supine position suggest underlying retroperitoneal etiologies and warrant further investigation
⚬ if subclinical varicocele (not visible or palpable) is the only finding on scrotal ultrasound performed for
acute scrotal pain, evaluation should continue for true cause of pain
⚬ References - 1 ,3 , Transl Androl Urol 2017 May;6(Suppl 1):S20
● spermatocele
⚬ clinical diagnosis based on palpation of freely moveable, fluctuant, and transilluminating lump or
mass 3
⚬ spermatocele may be distinguished from hydrocele by ability to palpate above the mass 3
⚬ scrotal ultrasound may be helpful if diagnosis is uncertain 3
● idiopathic acute edema
⚬ findings on ultrasound include 4
– characteristic marked edematous thickening of the scrotal wall and normal appearance of the
testes and epididymis
– small reactive hydrocele may be observed
– hypervascular peritesticular scrotal soft tissues on color Doppler images, which are highly
suggestive of the diagnosis (“fountain sign”)
Approach Based on Suspected Nonscrotal Causes
● incarcerated or strangulated hernia
⚬ general considerations for diagnosis
– inguinal hernias in men typically diagnosed clinically by physical exam, with evidence of visible
bulge or easily palpable mass while straining with examining finger in external ring
– tense, extremely tender groin mass, with or without signs of sepsis, may indicate a strangulated
hernia, which is a surgical emergency
– patients with typical symptoms in absence of physical findings and/or with questionable swelling
require further investigation with imaging techniques to rule out occult hernia or other condition
⚬ see Diagnosis in Groin Hernia in Adults and Adolescents
● kidney colic 4
⚬ gross or microscopic hematuria may indicate alternative diagnosis to scrotal pathology

⚬ diagnosis confirmed by imaging, which may include ultrasound, computed tomography scan, or both
⚬ in addition, in clinically indeterminant cases or when normal scrotum is noted on ultrasound, kidney
ultrasound may be helpful to assess for urinary tract obstruction (calculus or hydronephrosis)
⚬ see Diagnosis in Nephrolithiasis in Adults
● if abdominal aortic aneurysm rupture, acute appendicitis, or acute pancreatitis suspected, see
⚬ Abdominal Aortic Aneurysm (AAA) Rupture

⚬ Appendicitis in Adolescents and Adults
⚬ Acute Pancreatitis in Adults
Blood Tests
● blood tests for workup of acute scrotal pain will depend on suspected underlying etiology; for blood tests
for specific conditions, including
⚬ infection and inflammation causes, see Diagnosis in
– Necrotizing Fasciitis for Fournier gangrene

– Henoch-Schonlein Purpura
– Behcet Syndrome
– Polyarteritis Nodosa
⚬ traumatic testicular injuries, see Diagnosis in Traumatic Genitourinary Tract Injuries in Adults
⚬ other scrotal-related causes, see Diagnosis in Varicocele in Children and Adolescents and Diagnosis
and Staging in Testicular Cancer
⚬ nonscrotal-related causes, see Diagnosis in
– Nephrolithiasis in Adults for kidney colic

– Extragonadal Germ Cell Tumors of Mediastinum and Retroperitoneum for retroperitoneal tumors
Urine Studies
● urinalysis
⚬ to assess for urinary tract infection 1 ,2 ,3 ,4
– positive (abnormal) result
● may be present in acute epididymitis, especially in conjunction with dysuria or other features of
urinary tract infection
● does not rule out testicular torsion
– negative (normal) result
● does not rule out epididymitis

● does not exclude testicular torsion
● midstream urine specimen for microscopy, culture, and sensitivity to rule out sexually transmitted
2,3,4
infection
● for findings on urine studies
⚬ for testicular torsion, see Diagnosis in Testicular Torsion

⚬ for infection and inflammation, see Diagnosis in
– Acute Epididymitis
⚬ for traumatic testicular injuries, see Diagnosis in Traumatic Genitourinary Tract Injuries in Adults
⚬ for kidney colic, see Diagnosis in Nephrolithiasis in Adults
Imaging
● in the setting of acute scrotal pain, imaging may be used 1 ,2 ,3 ,4
⚬ as first-line investigations; for example, ultrasound is first-line imaging modality for some acute
scrotal disorders such as blunt scrotal trauma or testicular cancer 4
⚬ if clinical diagnosis is inconclusive; for example, Doppler ultrasound may be used to confirm diagnosis
4
of inguinal hernia when unclear from clinical evaluation
⚬ to help differentiate scrotal disorders from one another; examples include
– Doppler ultrasound, which may be used to help differentiate
● testicular torsion (decreased or absent blood flow) and acute epididymitis (increased blood
flow) 1 ,3
● hydrocele, large epididymal cyst, and inguinoscrotal hernia 3

– magnetic resonance imaging, which may be used to help differentiate hypovascular tumor and
4
segmental testicular infarction
⚬ to evaluate extent and severity of disease
● for imaging findings for causes of acute scrotal pain
⚬ for testicular torsion, see Diagnosis in Testicular Torsion

⚬ for infection and inflammation causes, see Diagnosis in
– Acute Epididymitis
– Necrotizing Fasciitis for Fournier gangrene
– Behcet Syndrome
⚬ for traumatic testicular injuries, see Diagnosis in Traumatic Genitourinary Tract Injuries in Adults
⚬ for other scrotal-related causes, see Diagnosis and Staging in Testicular Cancer and Diagnosis in
– Hydrocele in Adults and Adolescents

– Varicocele in Children and Adolescents
⚬ for nonscrotal-related causes, see Diagnosis in
– Groin Hernia in Adults and Adolescents

– Nephrolithiasis in Adults for kidney colic
– Abdominal Aortic Aneurysm (AAA) Rupture
– Extragonadal Germ Cell Tumors of Mediastinum and Retroperitoneum
● American College of Radiology (ACR) Appropriateness Criteria for acute onset of scrotal pain (without
trauma or antecedent mass) can be found at J Am Coll Radiol 2019 May;16(5S):S38
Management
Management Overview
● management mainly consists of treating the underlying cause of pain 1 ,2 ,3 ,4
● the following causes of acute scrotal pain typically require emergent or urgent management, which may
include surgical exploration or repair, referral to specialist (urology), and/or initiation of antimicrobial
therapy
⚬ testicular torsion 1 ,3
– management options include immediate scrotal exploration, detorsion, and orchidopexy

– torsion of testicular appendage does not necessarily require surgical intervention
⚬ traumatic testicular rupture
– management options include surgical exploration, orchidopexy, orchiectomy, and reconstruction

– conservative management may be appropriate for small hematocele (< 3 times the size of
contralateral testis) and testicular dislocation
⚬ acute epididymitis (acute epididymo-orchitis), which should be treated with antibiotic therapy 1 , 3
⚬ Fournier gangrene; mainstays of care are prompt and complete surgical debridement combined with
immediate and aggressive antimicrobial therapy
⚬ incarcerated or strangulated hernia, which requires urgent surgical referral; small, reducible hernia
may not require urgent surgery 3
⚬ testicular cancer 1 , 3
– requires prompt urology referral

– management depends on type of testicular cancer and clinical stage; options include surgery,
chemotherapy, radiation therapy, or surveillance
● causes of acute scrotal pain that do not typically require urgent treatment and may be managed with
surgical exploration or repair, referral to specialist (urologist), initiation of medical therapy, or
surveillance include
⚬ segmental testicular infarction - historically managed with surgery; conservative management
reported in patients with high certainty of diagnosis (with testicular cancer ruled out)
⚬ Behcet syndrome - management is guided by the affected organs, severity of the disease, and patient
characteristics and may include topical (such as local corticosteroids) or systemic therapies (such as
colchicine, cyclosporine A, azathioprine, interferon alfa, and tumor necrosis factor-alfa antagonists)
⚬ hydrocele - management is guided by presence or absence of symptoms, and options include
watchful waiting, surgery, or aspiration and sclerotherapy
⚬ varicocele - surgical management is controversial; considerations for surgery include recurrence, size
of varicocele, and presence of symptoms
⚬ spermatocele - if asymptomatic, intervention likely not required; if symptomatic, refer for
consideration of surgical excision
Cause-specific Management
Vascular Disruptions (Ischemia)
⚬ surgical emergency; goal of treatment is rapid restoration of blood flow to ischemic testis
– obtain prompt urologic consultation

– intervention should not be delayed
– there is typically a 4- to 8-hour window before permanent ischemic damage occurs
⚬ urgent surgical exploration should be performed in all cases of testicular torsion within 24 hours of
symptom onset, which includes
– detorsion of affected spermatic cord
– orchiopexy of contralateral testicle
– assessment of testicular viability
– orchiopexy or orchiectomy on affected testicle, depending on viability
● orchiopexy if affected testicle is deemed viable

● orchiectomy if affected testicle appears grossly necrotic or nonviable
● either is an option if affected testicle is questionably viable
⚬ manual detorsion can reduce severity of testicular torsion but should not supersede, delay, or replace
surgical intervention
⚬ see Management in Testicular Torsion for additional information
● torsion of testicular appendage
⚬ does not necessarily require surgical intervention 1
⚬ however, distinction between appendicular torsion and testicular torsion remains difficult; as a
general rule, surgical intervention is required in all cases in which Doppler ultrasonography
demonstrates decreased or absent testicular blood flow 1
● segmental testicular infarction
⚬ although consensus is lacking, management options include
– conservative management with surveillance in patients with high certainty of diagnosis (testicular
cancer ruled out)
– testis-sparing surgery
● reported as preferred surgical choice compared to radical orchiectomy, especially in younger

patients
● however, due to difficulty in achieving preoperative diagnosis and consideration for possible
testicular tumor (since radiologic features resemble those of testicular tumor), radical
orchiectomy often performed
● frozen section, if available, to enable testicle-sparing treatment
– surgical exploration or orchiectomy if extensive infarction or persistent pain

– References - Ann Med Surg (Lond) 2020 Jul;55:265, Exp Ther Med 2015 Mar;9(3):758
Infection and Inflammation
● acute epididymitis (epididymo-orchitis)
⚬ treat patients with clinically diagnosed epididymitis empirically
– treatment should not be delayed pending detection of causative pathogen but ideally should be
started after samples for laboratory testing obtained
– antibiotic choice guided by sexual and urologic history; examples include
● if acute epididymitis most likely caused by sexually transmitted chlamydia or gonorrhea, both
ceftriaxone and doxycycline would be administered
● if acute epididymitis likely caused by enteric organism only, levofloxacin would be prescribed
for 10 days
– see Management in Acute Epididymitis for guideline recommendations for antibiotic therapy in
patients with acute epididymitis
⚬ provide pain relief with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), scrotal
elevation, and ice packs
⚬ refer sex partners of men with confirmed or suspected Neisseria gonorrhoeae or Chlamydia
trachomatis for evaluation and treatment
⚬ follow up in 2-7 days after treatment initiation to evaluate clinical response
⚬ see Management in Acute Epididymitis for additional information
● Fournier gangrene (necrotizing fasciitis)
⚬ necrotizing fasciitis is a medical and surgical emergency requiring immediate intervention
⚬ mainstays of care are prompt and complete surgical debridement combined with immediate and
aggressive antimicrobial therapy
– early surgical intervention allows for both diagnosis and rapid source control
– repeated surgical debridement often needed to achieve complete source control
– for patients with systemic illness and shock, resuscitation performed similarly to septic shock
⚬ adjunctive antimicrobial regimen should be directed at probable pathogens (including streptococci,

methicillin-resistant Staphylococcus aureus, anaerobes, and enteric gram-negative organisms) and
– continued until repeated surgical debridements are unnecessary
– continued until clinical improvement is apparent
– continued 48-72 hours after defervescence
⚬ infectious disease consultation may be helpful in determining most appropriate regimen (especially in
cases in which unusual organisms suspected)
⚬ antimicrobial regimen may be modified to pathogen-directed therapy once causative pathogen(s)
identified or if unusual pathogen suspected
⚬ close monitoring and intensive supportive care may be required
⚬ see Management in Necrotizing Fasciitis for additional information
● noninfectious acute epididymitis - for medication-related, discontinue or reduce dosage of causative

agent, such as amiodarone, for rapid resolution and avoidance of unnecessary surgical interventions in
high-risk groups 1
⚬ treatment often requires only supportive care with attention to hydration and nutrition
⚬ see Management in Henoch-Schonlein Purpura for additional information
● Behcet syndrome
⚬ disease management guided by affected organ(s), extent and severity of involvement, and age and
gender of patient
⚬ for isolated oral and genital ulcers, use topical therapies such as local corticosteroids
⚬ for systemic therapy to alleviate oral and skin lesions, options may include colchicine, cyclosporine A,
azathioprine, interferon alfa, and tumor necrosis factor-alfa antagonists
⚬ see Management in Behcet Syndrome for additional information
⚬ management may vary based on systemic or isolated organ disease; examples include
– systemic disease; treatment may include glucocorticoids +/− additional immunosuppressive

therapy
– reported cases of isolated testicular vasculitis treated with only surgical excision (orchiectomy)
– Reference - J Med Case Rep 2019 Jul 31;13(1):236
⚬ see Management in Polyarteritis Nodosa for additional information
Trauma
● management of testicular trauma
⚬ nonoperative (conservative) management
– includes
● scrotal support
● analgesia, including NSAIDs
● ice packs
● bed rest for 24-48 hours
● antibiotic therapy if associated epididymitis or suspected urinary tract infection
– may be appropriate for
● small hematocele (< 3 times the size of contralateral testis)

● testicular dislocation
⚬ operative management
– includes surgical exploration, orchidopexy, orchiectomy, and reconstruction

– typically appropriate for
● testicular rupture
● large hematocele
● testicular dislocation (if manual repositioning is unsuccessful)
● penetrating scrotal injury
⚬ for burns
– nonoperative management includes silver sulfadiazine or topical antibiotic and negative pressure
dressing
– operative management includes surgical exploration irrigation, debridement of obvious nonviable
tissue, and reconstruction
⚬ see Management in Traumatic Genitourinary Tract Injuries in Adults for additional information
⚬ see specific recommendations from
– European Association of Urology (EAU) guideline on urologic trauma at EAU 2022 Mar
– American Urological Association (AUA) guideline on urotrauma at AUA 2020 Aug
Other Causes
● testicular cancer
⚬ refer patients with suspected testicular cancer to urologist 3
⚬ management depends on type of testicular cancer and clinical stage; options may include 3
– surgery such as orchiectomy or testicular-sparing surgery

– chemotherapy
– radiation therapy
– fertility preservation (sperm banking)
– surveillance
– see Management in Testicular Cancer for information
● hydrocele
⚬ refer to urologist if symptomatic (discomfort or heavy sensation after sport or physical activity) 3
⚬ management may include
– watchful waiting
● period of watchful waiting should precede surgery if hydrocele is small and asymptomatic
● hydroceles often resolve spontaneously, but further examination and treatment advised if they
persist > 1 year or are symptomatic
– surgical hydrocelectomy
– aspiration and sclerotherapy (may be alternative for patients not wanting surgery)
– see Management in Hydrocele in Adults and Adolescents
● varicocele
⚬ management of varicoceles in adults and adolescents
– in adults 1 ,3
● surgical intervention for pain is controversial
⚬ endovascular embolization may be initial treatment for symptomatic varicoceles

⚬ surgical ligation may be indicated for recurrent cases
● consult suggested for some settings, including
⚬ presence of right-sided varicocele

⚬ sudden onset of symptoms
⚬ patient age > 40 years
⚬ tense varicocele while supine
● if asymptomatic, small left-sided varicoceles usually need no treatment
– in adolescents (and children)
● repair is controversial
● indications for repair may include symptomatic varicocele (painful scrotum)
⚬ see Management in
– Varicocele in Adults
– Varicocele in Children and Adolescents
● spermatocele
⚬ if asymptomatic, no treatment is necessary 3

⚬ if symptomatic (cyst causes pain or discomfort), refer for consideration of excision; if cyst is size of
testicle, removal may be more likely 3
⚬ see Spermatoceles in Benign Urologic Conditions in Men for additional information
● acute idiopathic scrotal edema
⚬ management is conservative - NSAIDs

⚬ empirical oral antibiotics; symptoms usually resolve within 5 days
⚬ Reference - Urol Case Rep 2020 Jan;28:101014
Nonurologic Causes and Referred Pain
● inguinal hernia (reducible)
⚬ urgent surgical referral required for incarcerated or strangulated hernia 1 ,3
⚬ if small and reducible
– urgent surgery not typically required 3
– if symptomatic (episodes of pain and tenderness), intervention may be warranted 3

⚬ see Management in Groin Hernia in Adults and Adolescents for additional information
● kidney colic - see Management in Nephrolithiasis in Adults
● ruptured aortic aneurysm - see Management in Abdominal Aortic Aneurysm (AAA) Rupture
● acute appendicitis - see Management in Appendicitis in Adolescents and Adults
● acute pancreatitis - see Management in Acute Pancreatitis in Adults
Complications
● complications of testicular torsion include
⚬ testicular ischemia
– ischemic damage can cause morphologic changes in testicular histopathology and have adverse
effects on spermatogenesis
– approximate salvage rates reported based on timing of surgical exploration and detorsion
● 90%-100% if within 6 hours

● 50% if within 12 hours
● < 10% if after 24 hours
⚬ fertility may be affected, but long-term outcomes are not conclusive
– subfertility and infertility are consequences of direct injury to the testis, caused by decreased
blood supply from torsion and postischemic reperfusion injury from detorsion
● reduced fertility (impaired spermatogenesis) reported in up to 50%
● subfertility reported in 36%-39% of patients after torsion
– reported 50%-95% of patients have abnormal semen after torsion during long-term follow-up
– prolonged torsion and orchiectomy may have negative impact on fertility
⚬ see Complications in Testicular Torsion for additional information
● complications of acute epididymitis include
⚬ sepsis
⚬ extension of infection
⚬ testicular infarction
⚬ abscess formation
⚬ testicular atrophy
⚬ chronic pain and induration
⚬ infertility
⚬ see Complications in Acute Epididymitis for additional information
● complications of other infection and inflammation causes - see Complications in
⚬ Necrotizing Fasciitis (for Fournier gangrene)

⚬ Henoch-Schonlein Purpura
⚬ Behcet Syndrome
⚬ Polyarteritis Nodosa
● complications of traumatic testicular injuries include
⚬ erectile dysfunction
⚬ urethral stricture
⚬ infertility and testosterone production
⚬ infection
⚬ pain
⚬ chronic pain
⚬ testicular atrophy
⚬ see Complications in Traumatic Genitourinary Tract Injuries in Adults for additional information
● complications of hydrocele include
⚬ testicular damage
⚬ sociobehavioral complications such as self-consciousness, depression, decline in work performance,
sexual functioning, and social interactions and relationships
⚬ complications of hydrocelectomy, which are self-limited and include scrotal edema, wound infection,
and hematoma
⚬ see Complications in Hydrocele in Adults and Adolescents for additional information
● complications of varicocele include
⚬ in adults
– ipsilateral testicular hypotrophy

– sperm abnormalities, either alone or in combination, that may lead to infertility, such as low sperm
count (oligozoospermia), reduced sperm motility (asthenozoospermia), and abnormal sperm
morphology (teratozoospermia)
– infection in patients treated surgically
– see Complications in Varicocele in Adults for additional information
⚬ in adolescents, see Complications in Varicocele in Children and Adolescents for additional information
● complications of testicular cancer - see Complications in Testicular Cancer
Guidelines and Resources
Guidelines
International Guidelines
● World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST)
guideline on anorectal emergencies can be found at World J Emerg Surg 2021 Sep 16;16(1):48
● WSES and AAST guideline on kidney and urotrauma can be found in World J Emerg Surg 2019;14:54
United States Guidelines
● American Urological Association (AUA) guideline on urotrauma can be found at AUA 2020 Aug
● American College of Radiology (ACR) Appropriateness Criteria on acute onset of scrotal pain (without
trauma or antecedent mass) can be found at ACR 2018
● American Institute of Ultrasound in Medicine (AIUM) guideline on performance of scrotal ultrasound

examinations can be found in J Ultrasound Med 2015 Aug;34(8):1
● Centers for Disease Control and Prevention (CDC) treatment guideline on sexually transmitted infections
can be found in MMWR Recomm Rep 2021 Jul 23;70(4):1 or at CDC 2021 Jul 23 PDF
● Infectious Diseases Society of America (IDSA) and American Society for Microbiology (ASM) guideline on
utilization of microbiology laboratory for diagnosis of infectious diseases can be found at Clin Infect Dis
2018 Aug 31;67(6):e1
United Kingdom Guidelines
● British Association for Sexual Health and HIV (BASHH) national guideline on management of epididymo-
orchitis can be found in Int J STD AIDS 2021 Sep;32(10):884
● British Association of Urological Surgeons (BAUS) consensus document on management of male genital
emergencies - testicular trauma can be found in BJU Int 2018 Jun;121(6):840
European Guidelines
● European Association of Urology (EAU) guidelines on
⚬ pediatric urology can be found at EAU 2022 Mar

⚬ urologic infections can be found at EAU 2022 Mar
⚬ urologic trauma can be found at EAU 2022 Mar
● International Union Against Sexually Transmitted Infections 2016 European guideline on management of
epididymo-orchitis can be found in Int J STD AIDS 2017 Jul;28(8):744, correction can be found in Int J STD
AIDS 2017 Jul;28(8):844
Australian and New Zealand Guidelines
● New Zealand Sexual Health Society (NZSHS) 2017 guideline on epididymo-orchitis can be found at NZSHS
2017 Sep
Review Articles
● review of scrotal pain can be found in Korean J Urol 2015 Jan;56(1):3
● review of acute scrotal pain can be found in Aust Fam Physician 2013 Nov;42(11):790
● review of rare causes of acute scrotal pain in adults can be found in Ann Med Surg (Lond) 2020 Jul;55:265
● review of nonscrotal causes of acute scrotum can be found in J Ultrasound Med 2021 Mar;40(3):597
⚬ review of testicular torsion and acute scrotum can be found in Eur J Emerg Med 2016 Jun;23(3):160
⚬ review of pediatric testicular torsion can be found in Surg Clin North Am 2017 Feb;97(1):161
● epididymitis
⚬ review of epididymitis can be found in Am Fam Physician 2016 Nov 1;94(9):723

⚬ review of management of epididymo-orchitis can be found in Practitioner 2013 Apr;257(1760):21
● genital trauma
⚬ review of emergency management of genitourinary trauma can be found in Emerg Med Clin North
Am 2019 Nov;37(4):611
⚬ review of imaging of genitourinary trauma can be found in Radiol Clin North Am 2017 Mar;55(2):321
⚬ review of genitourinary injuries among military service members can be found in Transl Androl Urol
2018 Aug;7(4):646
● review of scrotal masses can be found in Am Fam Physician 2022 Aug;106(2):184
● review of evaluation of scrotal masses can be found in Am Fam Physician 2014 May 1;89(9):723
● other causes of acute scrotal pain
⚬ review of Henoch-Schonlein purpura with scrotal involvement can be found in J Pediatr Hematol
Oncol 2021 Aug 1;43(6):211
⚬ review of varicocele and testicular pain can be found in World J Mens Health 2019 Jan;37(1):4,
commentary can be found in World J Mens Health 2021 Oct;39(4):818
⚬ review of varicocele can be found in Transl Androl Urol 2017 May;6(Suppl 1):S20
● imaging reviews
⚬ review of scrotal ultrasound in the emergent setting can be found in Emerg Radiol 2018 Aug;25(4):341
⚬ review of imaging of traumatic injuries to the scrotum and penis can be found in AJR Am J Roentgenol
2014 Jun;202(6):W512
⚬ review of imaging modalities used in diagnosis and management of scrotal trauma can be found in
Curr Urol Rep 2017 Oct 28;18(12):98
MEDLINE Search
● to search MEDLINE for (Acute Scrotal Pain in Adults and Adolescents) with targeted search (Clinical
Queries), click therapy , diagnosis , or prognosis
Patient Information
● handout on scrotal lumps, pain, and swelling from Patient UK PDF
References
General References Used
The references listed below are used in this DynaMed topic primarily to support background information and for
guidance where evidence summaries are not felt to be necessary. Most references are incorporated within the text
along with the evidence summaries.
1. Gordhan CG, Sadeghi-Nejad H. Scrotal pain: evaluation and management. Korean J Urol. 2015 Jan;56(1):3-
11.
2. Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular pain in children and
adolescents. BMJ. 2015 Apr 2;350:h1563.
3. Sharp WMJ, Mackie S. The management of testicular masses and acute scrotal pain. J R Nav Med Serv.
2016;102(1):40-49.
4. Sweet DE, Feldman MK, Remer EM. Imaging of the acute scrotum: keys to a rapid diagnosis of acute
scrotal disorders. Abdom Radiol (NY). 2020 Jul;45(7):2063-2081.
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Acute Scrotal Pain in Adults and Adolescents - Approach To The Patient - DynaMed

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Acute Scrotal Pain in Adults and Adolescents - Approach To The Patient - DynaMed

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18/9/23, 19:14 Acute Scrotal Pain in Adults and Adolescents - Approach to the Patient - DynaMed

Updated 16 May 2022

Acute Scrotal Pain in Adults and Adolescents - Approach to the

● Many causes have similar or overlapping features at presentation.

Table 1: Clinical Presentation of Causes of Acute Scrotal Pain

Symptoms Findings on Associated

Testicular torsion – Sudden onset – High-riding or – Previous

Traumatic – Pain – Findings Recent trauma

Acute – Gradual onset – Focal Recent history of:

Symptoms Findings on Associated

Symptoms of UTI ● Tachycardia – Viral illness

Fournier – Severe pain – Fever, – Local trauma

Symptoms Findings on Associated

Incarcerated Severe pain over – Unable to feel N/A

Testicular cancer – Usually, – Mass/swelling Risk factor:

● The diagnostic approach may vary based on suspected cause, including:

⚬ vascular disruptions such as testicular torsion, torsion of testicular appendage, or segmental

Table 2: Summary of Findings on Diagnostic Testing of Causes of Acute Scrotal Pain

Diagnostic Findings on Findings on

Testicular torsion – Clinical Normal urinalysis – Early finding:

Traumatic – For blunt Possible – Heterogeneou

Acute – Diagnosis May have positive – Performed to

Fournier – Diagnosis – Leukocytosis Findings include:

Incarcerated – Clinical N/A – Sonographic

Diagnostic Findings on Findings on

Testicular cancer – Diagnosis May have positive Well-defined,

Diagnostic Findings on Findings on

Abbreviations: AFP, alpha fetoprotein; Beta-hCG, beta-human chorionic gonadotropin; CBC,

● Traumatic Genitourinary Tract Injuries in Adults

● Varicocele in Children and Adolescents

● Hydrocele in Adults and Adolescents

● vascular causes include

● infectious or inflammatory causes include

⚬ epididymitis, acute epididymo-orchitis, and orchitis

● scrotal and testicular trauma include

⚬ blunt trauma such as testicular rupture and hematocele

● other scrotal-related causes may include

● nonscrotal causes include

⚬ kidney colic and ureteral stones

● incidence/prevalence of some causes of acute scrotal pain

– in adults, noticeable hydrocele reported in about 1% of male persons

Causes Requiring Urgent Medical or Surgical Intervention

● causes typically requiring urgent intervention include 1 ,2 ,3 ,4

Causes According to Frequency

⚬ testicular torsion (typically occurs in male adolescents aged 12-18 years)

● other causes may include

⚬ strangulated inguinal hernia - reported to occur in 5% of cases

Causes According to Mechanism

Vascular Disruptions (Ischemia)

⚬ typically occurs in male adolescents aged 12-18 years

● usually due to congenital malformation of processus vaginalis

⚬ see Testicular Torsion for additional information

● torsion of testicular appendix (cyst of Morgagni) 2 ,4

⚬ testicular appendage is a small embryologic remnant at upper pole of testis

Infection and Inflammation

Acute Epididymitis, Acute Epididymo-orchitis, and Orchitis

● orchitis refers to inflammation of the testes alone 3 ,4

– most commonly Neisseria gonorrhoeae or Chlamydia trachomatis

⚬ in patients > 35 years old

● most commonly caused by E. coli

● mumps (most common cause of isolated orchitis, especially in children)

⚬ Candida spp. (commonly Candida albicans, less commonly Candida glabrata)

● parasites such as Schistosoma haematobium, Schistosoma mansoni, Toxoplasma gondii, and