Can Scrotal Pain Be Referred from Abdominal Concerns?
Yes, scrotal pain can absolutely be referred from intra-abdominal pathology, and failure to recognize this can lead to missed life-threatening diagnoses.
Mechanism of Referred Scrotal Pain
Intra-abdominal contents can reach the scrotum through a patent processus vaginalis, causing scrotal pain and swelling without primary scrotal pathology 1. This anatomical communication allows conditions causing hemoperitoneum to manifest as scrotal symptoms 1.
Specific Abdominal Causes That Present as Scrotal Pain
Life-threatening conditions that can present solely as acute scrotal pain include:
- Splenic rupture - Can present as acute scrotal swelling and pain, particularly in anticoagulated patients, with the diagnosis being a communicating hematocele secondary to occult splenic rupture 1
- Aneurysm rupture or retroperitoneal hemorrhage - Can manifest clinically only as acute scrotum 2
- Renal colic - A well-recognized cause of referred scrotal pain 2
- Pancreatitis - Can present with acute scrotal symptoms 2
- Pelvic inflammation - May refer pain to the scrotum 2
- Primary abdominal or pelvic tumors and metastases - Can cause referred scrotal pain 2
- Muscle injuries in the groin/thigh region - May present as scrotal pain 2
Critical Diagnostic Algorithm
When evaluating scrotal pain, the following approach is essential:
Step 1: Rule out testicular torsion first - This remains the surgical emergency requiring intervention within 6-8 hours 3, 4
Step 2: If scrotal ultrasound is normal, do not stop the workup 2
Step 3: Expand imaging to include abdomen, groin, and thighs - In patients with acute scrotal symptoms and normal scrotal ultrasound findings, nonscrotal causes must be considered, and ultrasound investigation of the abdomen, groin, and thighs is indicated 2
Step 4: Consider risk factors for intra-abdominal bleeding - Any patient with risk factors for bleeding (anticoagulation, trauma history, known aneurysm) presenting with scrotal swelling should have both scrotal AND abdominal imaging 1
Key Clinical Pitfalls to Avoid
- Do not assume scrotal pain always originates from scrotal structures - The differential diagnosis includes testicular, scrotal, AND intra-abdominal pathology 1
- Do not discharge patients with normal scrotal ultrasound without considering referred pain - Nonscrotal lesions can present clinically only with acute scrotal pain 2
- Hematocele should trigger abdominal investigation - Any cause of hemoperitoneum may cause hematocele, and hematocele should be considered in the differential diagnosis of acute scrotal swelling in patients with bleeding risk factors 1
Chronic Scrotal Pain Considerations
For chronic scrotal content pain (≥3 months duration), referred pain from the spine, abdomen, and retroperitoneum is a recognized etiology 5. The evaluation should specifically assess for these extra-scrotal sources when scrotal examination and imaging are unrevealing 5.