Testicular Pain
  Testicular pain is a common symptom that can afflict males of any age and a condition we frequently treat at Alliance Urology Specialists. Testicular pain can be either acute or chronic. Sudden onset or acute testicular pain is a medical emergency demanding rapid diagnosis and treatment. Chronic testicular pain can be progressively debilitating, and the cause is often not readily apparent. Testicular cancer does not usually present with pain, but with a hard mass in the testicle.
Acute testicular or scrotal pain is frequently sudden in onset and can be quite severe. The most common causes of acute pain include but are not limited to:

Epididymitis is an infection of the epididymis, a structure composed of tightly packed tubules that carry the sperm from the testicle to the vas deferens. The vas deferens carries the sperm to the urethra, the tube from the bladder through the penis.  Epididymitis is primarily caused by backflow of urine up the vas deferens to the epididymis. This backflow is often the result of an abrupt activity that increases bladder pressure such as heavy lifting, stepping off a curb unexpectedly or landing after a parachute jump, but many patients can’t recall an inciting event. The urine causes inflammation in the tubes which allows infection to set in. The pain associated with epididymitis can be very severe, and the scrotum can become red and swollen.  Associated symptoms can include fever, nausea, and abdominal pain. Treatment usually includes antibiotics for 10-14 days, anti-inflammatories, ice packs, and elevation. If treatment is delayed, a chronic condition can develop.

Testicular torsion is a condition that is most common from late adolescence to young adulthood, and is often associated with the onset of puberty when the testicles begin to enlarge. Most testicles are attached within the scrotum so that they will not twist on their blood supply, but men prone to torsion have less secure attachments, and the testicle can twist more than 360 degrees causing obstruction of the blood supply. The pain with testicular torsion can be very severe, and is often associated with nausea and vomiting. The onset is usually rapid, and the pain can be intermittent if the testicle untwists and then twists again. Testicular torsion is a true surgical emergency. A testicular ultrasound, offered at Alliance Urology Specialists, can clarify the diagnosis by confirming the lack of blood flow in the affected testicle. If the testicle is not detorsed or untwisted quickly, testicular death will occur. Untwisting the testicle can occasionally be done successfully without surgery to provide pain relief, but surgery to untwist the testicle and secure it firmly in the scrotum should be done within six hours of the onset of pain for the best chance at testicular preservation. An interval of torsion greater than 12 hours will result in testicular loss in most cases. If torsion is detected at surgery, the other testicle needs to be secured as both sides will commonly have the same loose attachments.

Torsion of a testicular appendage
is a condition that can mimic testicular torsion, but the pain is usually not as severe. During fetal development, we are all initially equipped with male and female genital ducts, but hormonal influences will result in the involution or disappearance of the unneeded set. Frequently, there are small remnants of these structures, called the appendix testes and the appendix epididymis depending on their location, that remain after birth. These appendages are quite small measuring between ¼ and ½ of an inch in length, but they too can twist and cut off their blood supply. When torsion occurs, the appendix will initially swell then become tender and bluish in color.  If a patient is examined soon after onset, a blue dot can be seen beneath the skin particularly if the patient has a fair complexion. If the blue dot is seen, then the treatment can be observation. Surgical excision of the torsed appendix can speed recovery as it can take 1-2 weeks for the inflammation to resolve without treatment. If too much time passes before evaluation, the inflammation becomes more severe and the blue dot sign is lost. The diagnosis becomes less clear, and surgical intervention to remove the appendage will often be required to speed recovery and insure that the testicle torsion is not the culprit.

Delayed post vasectomy pain is an infrequent condition where the epididymis, which is under pressure from continued sperm production by the testicle, may leak a little sperm into the surrounding tissues. This is commonly referred to as an “epididymal blowout” and results in the sudden onset of testicular pain followed by the appearance of a marble sized, hard, tender knot on the perimeter of the testicle.  The inflammation will mimic epididymitis, but if there has been a vasectomy, urine cannot reach the epididymis to cause the problem. This condition is best managed with ice and anti-inflammatory medication like Ibuprofen or Naproxen. Antibiotics can be prescribed if the diagnosis is not clear.

Testicular trauma usually from a blow to the testicle can result in acute testicular pain as most men are aware. Usually, the initial sharp pain is transient followed by a dull achiness, but if the pain remains severe or is associated with significant swelling, testicular rupture needs to be considered. Testicular torsion can also be precipitated by trauma. A scrotal ultrasound will help determine whether the testicle is ruptured or torsed. A rupture will be associated with a disruption of the capsule of the testicle, presence of fluid, or blood around the testicle. The ultrasound can also identify testicular bruising or subcapsular hematomas. A ruptured testicle should be repaired surgically and may require removal if severely injured.

Secondary causes of acute testicular pain can include kidney stones, herniated discs, and hernias. The nerve supply for the kidney and testicle has a similar origin so kidney pain can radiate to the testicle. A ruptured disc compressing a spinal nerve root can cause variably severe achy testicular pain that is often positional. The testicular innervation is primarily through the L1 nerve root. Pain radiating into the leg, scrotum, and inner thigh is often associated with the nerve root pain. An inguinal hernia can occasionally cause acute testicular pain, but the pain symptoms with a hernia tend to be more chronic.

Diagnosing the cause of acute testicular pain requires:

A thorough history and physical exam.
Urine culture if indicated
Gonorrhea and Chlamydia testing in at risk individuals
Scrotal Ultrasound with Doppler flow for suspected torsion or trauma
Surgical exploration if time appropriate studies are not available in a proper time frame to insure testicular salvage
Alliance Urology Specialists recognizes the need for prompt evaluation and management of acute scrotal and testicular pain. We have the doctors and the support staff to provide a comprehensive diagnostic workup and treatment. We are located adjacent to a full service hospital and an out-patient surgical center should emergent surgical intervention be required. If you or your child develops acute testicular or scrotal pain, don’t delay. Seek treatment immediately.


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