What are the treatment options for scrotal swelling?

Treatment of Scrotal Swelling

Treatment of scrotal swelling depends critically on the underlying etiology, with testicular torsion requiring immediate surgical exploration within 6-8 hours, while infectious causes respond to antimicrobial therapy and most other causes resolve with conservative management. 1

Immediate Triage: Rule Out Surgical Emergencies

The first priority is distinguishing testicular torsion from other causes, as delayed treatment beyond 6 hours can cause irreparable testicular damage 2:

• Testicular torsion requires immediate urological consultation and prompt surgical exploration—this is the definitive treatment 1
• Emergency evaluation is indicated when pain onset is sudden, pain is severe, or initial testing does not support urethritis or urinary tract infection 2
• Torsion occurs more frequently in adolescents and patients without evidence of inflammation or infection 2
• Surgical outcomes are better when intervention occurs within 12 hours of symptom onset 1

Testicular rupture and hematocele from blunt trauma also require early surgical intervention for best long-term results 3

Treatment by Etiology

Epididymitis/Epididymo-orchitis (Most Common Cause)

This is the single most common cause of scrotal swelling, with approximately 600,000 cases annually in the United States 2, 1:

For patients <35 years (likely gonococcal or chlamydial infection):

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 2

For patients ≥35 years (likely enteric organisms) or cephalosporin/tetracycline allergy:

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 2

Adjunctive conservative measures:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2, 1

Critical follow-up: Failure to improve within 3 days requires reevaluation of diagnosis and therapy 2. Persistent swelling after antimicrobial completion warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 2.

Torsion of Testicular Appendages

This is the most common cause in prepubertal boys 1:

• Conservative management with analgesics and scrotal support 1
• Symptoms typically resolve spontaneously 1

Hydrocele

The most common extratesticular cause of scrotal swelling 4, 5:

• Conservative management for uncomplicated cases 4
• Surgical intervention reserved for symptomatic or large hydroceles 4

Acute Idiopathic Scrotal Edema

A rare, self-limiting condition primarily affecting prepubertal boys but can occur in adults 1, 6:

• Expectant management with NSAIDs for inflammation relief 6
• Symptoms typically resolve within 72 hours 6

Scrotal Swelling from Acute Pancreatitis

A rare complication that usually resolves spontaneously 7:

• Conservative medical management with diuretics (e.g., Lasix) and leg elevation 7
• Swelling typically diminishes over 8 days 7

Intratesticular Hematoma (Without Rupture)

Can be treated conservatively when detected on ultrasound without accompanying testicular rupture 3

Diagnostic Imaging to Guide Treatment

Duplex Doppler ultrasound is the first-line imaging modality and distinguishes extratesticular (almost always benign) from intratesticular (potentially malignant) causes 2, 1, 4, 5:

• Sensitivity 69-96.8%, specificity 87-100% for testicular torsion 1
• Key findings for torsion: decreased/absent blood flow, "whirlpool sign" of twisted spermatic cord 1
• Epididymitis shows enlarged epididymis with increased blood flow 1
• Identifies hydroceles, masses, and other structural abnormalities 4, 5

Common Pitfalls to Avoid

• Do not delay surgical consultation for suspected torsion based on normal urinalysis—normal urinalysis does not exclude torsion 2, 1
• Beware false-negative Doppler evaluations with partial torsion or spontaneous detorsion 1
• Torsion is rare in patients >35 years but still must be considered 2, 1
• Significant overlap exists in clinical presentation between different causes, making imaging essential in equivocal cases 2, 1
• Hospitalization should be considered for severe pain suggesting torsion, testicular infarction, or abscess, or when patients are febrile or potentially noncompliant 2