What are the conservative management options for scrotal pain?

Conservative Management of Scrotal Pain

For acute scrotal pain, conservative management consists of bed rest, scrotal elevation, and analgesics until fever and local inflammation subside, specifically recommended for epididymitis and epididymo-orchitis after ruling out testicular torsion. 1

Initial Triage: Rule Out Surgical Emergencies First

Before initiating any conservative measures, you must immediately exclude testicular torsion, which requires surgical intervention within 6-8 hours to prevent testicular loss. 2 Conservative management is only appropriate after this life-threatening condition has been ruled out through clinical assessment and Doppler ultrasound. 1

Key Clinical Distinguishing Features:

• Testicular torsion: Abrupt onset of severe pain, negative Prehn sign (no relief with elevation), more common in adolescents 2
• Epididymitis/epididymo-orchitis: Gradual onset of pain, positive Prehn sign (relief with elevation), more common in adults over 25 years 2
• Normal urinalysis does NOT exclude either condition 2

Conservative Treatment Protocol for Epididymitis/Epididymo-orchitis

Once infectious/inflammatory causes are confirmed as the diagnosis, implement the following conservative measures:

Non-Pharmacologic Interventions:

• Bed rest until fever and local inflammation have subsided 1
• Scrotal elevation using supportive underwear or towel support to reduce venous congestion 1
• Avoid sexual intercourse until patient and partner complete therapy and are asymptomatic 1

Pharmacologic Management:

Analgesics for Pain Control:

• NSAIDs are recommended for managing pain in acute inflammatory conditions 1
• Continue until local inflammation resolves 1

Antimicrobial Therapy (required in addition to conservative measures):

• For sexually transmitted pathogens (age <35 years): Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1
• For enteric organisms or antibiotic allergies: Ofloxacin 300 mg orally twice daily for 10 days 1

Adjunctive Therapy for Specific Conditions:

For Peyronie's Disease with Active Pain:

• Tadalafil 5 mg daily has demonstrated pain improvement and lower curvature progression rates versus controls 1
• NSAIDs may help manage active-phase penile pain 1
• Low-intensity extracorporeal shockwave therapy (LI-ESWT) shows positive results for pain relief 1

Conservative Management of Chronic Scrotal Pain

For chronic orchialgia without identifiable acute pathology, conservative measures should be attempted before surgical referral. 3, 4

Initial Conservative Approach:

• Supportive underwear for continuous scrotal support 4
• NSAIDs for anti-inflammatory effect 4
• Avoid activities that exacerbate pain 4
• Trial of antibiotics if low-grade infection suspected 4

When Conservative Measures Fail:

• Refer to urology for consideration of microsurgical denervation, epididymectomy, or vasovasostomy if conservative treatment fails after 3 months 4
• Multidisciplinary team approach including pain management and psychology may be beneficial 3

Special Considerations and Critical Pitfalls

Segmental Testicular Infarction:

• Management is typically conservative with NSAIDs and observation 5
• Repeat ultrasound may be required if not apparent on initial imaging 5
• Some cases require surgical intervention if pain persists 5

Torsion of Testicular Appendage:

• Usually self-limited and managed conservatively with NSAIDs and scrotal support 2
• Most common in prepubertal boys 2

Follow-Up Requirements:

• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Persistent swelling and tenderness after completing antimicrobial therapy warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, or tuberculous/fungal epididymitis 1

Critical Warnings:

• Never delay imaging or surgical consultation in diabetic patients with acute scrotal swelling, as diabetes increases risk of rapid progression to life-threatening Fournier's gangrene 6
• Do not assume pain is neuropathic without ruling out acute pathology, especially in diabetic patients with autonomic neuropathy who may have masked pain responses 6
• Ultrasound has a 30% false-negative rate for partial testicular torsion; proceed to surgery if clinical suspicion remains high despite normal Doppler 2