What are the causes of testicular pain?

Causes of Testicular Pain

The three most common causes of acute testicular pain are testicular torsion, torsion of testicular appendage, and epididymitis/epididymoorchitis, accounting for approximately 85-90% of cases. 1

Common Causes of Testicular Pain

Acute Causes

• Epididymitis/Epididymoorchitis: Most common cause in adolescents and adults, characterized by more gradual onset, pain relief when testicle is elevated (positive Prehn sign), and increased blood flow on ultrasound 1
• Testicular Torsion: Surgical emergency with bimodal distribution (more common in neonates and postpubertal boys), requires treatment within 6-8 hours to prevent testicular loss, characterized by sudden onset of severe pain and negative Prehn sign 1, 2
• Torsion of Testicular Appendage: Most common cause in prepubertal boys, may present with "blue dot sign" (visible through skin in 21% of cases) 1
• Trauma: Direct injury to the testicle causing pain and swelling 1
• Testicular Tumors: May present with acute pain when hemorrhage or infarction occurs within the tumor 1, 3
• Idiopathic Scrotal Edema: Usually painless with marked thickening of scrotal wall, more common in children 1
• Hydrocele: Collection of fluid around the testicle that may cause discomfort 1
• Inflammation of Tunica Vaginalis: Can cause acute scrotal pain 1

Less Common Acute Causes

• Scrotal Abscess: Localized infection with pus collection 1
• Fournier's Gangrene: Necrotizing infection of the genital region 1
• Strangulated Inguinal Hernia: Intestinal contents trapped in scrotum causing pain 1
• Segmental Testicular Infarction: Uncommon cause in adult men, typically presenting with focal testicular pain 1, 3
• Scrotal Fat Necrosis: Often in prepubescent boys with recent cold exposure, presents with bilateral intrascrotal masses caudal to testes 1
• Referred Pain: From mid-ureteral stones, appendicitis, or aortic/iliac aneurysms 4, 3

Chronic Causes

• Chronic Orchialgia: Defined as pain lasting at least 3 months that interferes with daily activities 4
• Post-Vasectomy Pain: May be due to functional obstruction or spermatic granuloma 5
• Varicocele: Dilated veins in the scrotum affecting 15% of men, with 2-10% experiencing pain described as dull, aching, or throbbing 6
• Epididymal Cysts: Fluid-filled sacs that can cause discomfort 1
• Nerve Entrapment: Due to perineural fibrosis or previous surgical procedures 4
• Idiopathic Pain: Approximately 25-50% of chronic testicular pain has no identifiable cause 4

Diagnostic Approach

• Ultrasound with Doppler: First-line imaging for acute scrotal pain, can differentiate between various causes 1
• Advanced Ultrasound Techniques: Contrast-enhanced ultrasound, microvascular imaging, and shear wave elastography may help in difficult cases 1
• MRI: May be useful when ultrasound is inconclusive, particularly for testicular torsion diagnosis 1
• Radionuclide Imaging: Less commonly used, has been largely replaced by Doppler ultrasound 1

Clinical Pearls and Pitfalls

• Time-Critical Diagnosis: Testicular torsion requires surgical intervention within 6-8 hours to prevent permanent damage 1, 2
• Overlapping Presentations: Clinical presentations of the three most common causes can overlap, making accurate diagnosis challenging 1
• Age Considerations: Epididymitis is most common in adults, torsion of testicular appendage in prepubertal boys, and testicular torsion has a bimodal distribution 1
• Prehn Sign: Pain relief when testicle is elevated suggests epididymitis, while persistent pain suggests torsion 1
• Systemic Conditions: Consider rare systemic causes like vasculitis, pancreatitis, or brucellosis in patients with acute scrotal pain and systemic symptoms 3