Acute Scrotal Pain

Department of the Navy
Bureau of Medicine and Surgery

Acute scrotal swelling poses one of the more challenging clinical dilemmas in medicine. Distinguishing benign conditions from the acute scrotum is the key to managing these patients. The acute scrotum can be defined as any condition of the scrotum or intrascrotal contents requiring emergent medical or surgical intervention. Although rarely fatal, acute scrotal pathology can result in testicle infarction and necrosis, testicular atrophy, infertility, persistent testalgia, and significant morbidity.

The correct diagnosis of the acute scrotum is not always obvious, but a thorough history, physical exam, and use of basic laboratory studies can aid in distinguishing benign from surgical conditions. However, patients may present with an atypical history and physical exam. They may often delay presenting for help until far into the course of the illness when the physical exam is obscured by scrotal edema. Patient discomfort may limit obtaining a thorough physical exam. Ultimately, the most important question to be addressed is whether the testicle is adequately perfused.

Differential Diagnosis

The differential diagnosis of acute scrotal swelling can be divided most easily into painful and painless categories. The sources of painful scrotal swelling include testicular torsion, torsion of a testicular appendage, epididymitis, orchitis, an incarcerated hernia, an infarcted germ cell tumor, scrotal cellulitis and fasciitis, and post-traumatic causes. Painless etiologies for acute scrotal swelling may include hernias, varicocoeles, hydrocoeles, spermatocoeles, epididymal cysts, and germ cell tumors of the testis.

Testicular torsion may occur at any age and is the diagnosis that must be excluded when a patient presents with an acutely swollen scrotum. The patient will often describe the paroxysmal onset of sharp, debilitating pain in the scrotum. Most often there is no inciting event and the patient may describe being awakened at night with the pain. The testicle may be described as high riding in the scrotum with associated scrotal erythema and edema. Often there are no associated irritative voiding symptoms, burning on urination, or urethral discharge. If the patient presents early in the course of the torsion, the exam will often confirm the diagnosis. The testis is frequently firm to hard, fixed to the dartos and scrotal wall. The testicle may be exquisitely tender, but this is not universal. It may be high riding in the scrotum. The ipsilateral cremasteric reflex is almost universally absent, but if the contralateral reflex is missing, the significance of the finding is less helpful. The spermatic cord will be foreshortened and thickened. The epididymis may assume a medial, lateral, or anterior position. Because of venous congestion, the testis is usually larger than the unaffected side. Urinalysis and culture is typically normal in the early course of testicle torsion. The diagnosis of torsion is often confirmed with Doppler ultrasound. The absence of blood flow within the testicle is diagnostic. Ultrasound of a recently detorsed testicle may show an enlarged testicle with increased blood flow throughout. The key to torsion of the testicle is recognizing the presence of the torsion and immediate referral for surgical orchiopexy. The testicle must have its blood supply returned within 6 hours to avoid permanent damage. If the patient is suspected to have torsion of the testicle, emergent referral to the nearest facility with a surgeon capable of performing an orchiopexy is mandatory.

Manual detorsion of the testicle may be attempted as a temporizing measure. Detorsion is most frequently successful when the testicle is rotated toward the respective outer thigh. The physician should rotate the testicle outward as if opening a book (clockwise with the right hand, counter clockwise with the left). The testicle may need to be rotated more than 360 degrees. Successful detorsion is characterized by significant relief of the patient’s symptoms. The patient still must be referred for emergent surgical exploration and orchiopexy.

Torsion of a Testicular Appendage

Torsion of a testicular appendage can mimic testicular torsion, but the symptoms are often not as severe. In patients with thin scrotal skin, the torsed appendage may present with a visible "blue dot" at the pole of the testicle. Tenderness is usually isolated to that area and the testis is usually neither enlarged nor tender. The epididymis is in the correct anatomic position. There may be impressive scrotal swelling if the patient has delayed seeking medical attention. Urinalysis and culture are generally normal early in course of the disease. Ultrasound may be required if the diagnosis is in question. No surgery is required. The treatment is supportive with anti-inflammatory medications, scrotal elevation, cold packs, and rest.

Epididymitis occurs more frequently than testicular torsion as males grow beyond adolescence. Most patients will describe the gradual onset of increasingly intense pain in the testicle and scrotum for some period of time before presentation. The pain may, however, have an acute onset, thus leading to the difficulty distinguishing this from torsion of the testicle. Pain with epididymitis may radiate along the spermatic cord to the lower abdomen and may even reach the flank. The patient may describe having burning on urination, irritative voiding symptoms, and a urethral discharge. On physical exam, the epididymis is exquisitely tender, often enlarged, and scrotal edema may be present. As the disease progresses, the epididymis may no longer be distinguishable from the testis, the cord may become thickened, and the patient may develop a reactive hydrocoele. The pain may be diminished with elevation of the testicle (Prehn’s sign). Laboratory studies may help to confirm the diagnosis. A CBC may show leukocytosis with a left shift. Urinalysis will typically show pyuria, hematuria, and bacteriuria. Urine culture may grow coliform bacteria, neisseria species, or chlamydia. It is always necessary to see these patients back to document full resolution of the symptoms. Although rare, patients with testicular tumors may present with a reactive epididymitis as the only finding on exam. Two to 4 weeks of appropriate antibiotic therapy should be enough time for an epididymitis to resolve.

Severe epididymitis can progress to epididymo-orchitis, an infection of the entire testicle. These patients are at significant risk for complications, such as testicular necrosis, abscess formation, eventual testicular atrophy, infertility, and testalgia. Etiologies for orchitis in addition to progression of epididymitis include mumps orchitis, tuberculous orchitis, granulomatous orchitis, and syphilitic gummas. If the patient is suspected to have an epididymo-orchitis and it resolves completely with antibiotics, no referral is necessary. However, referral to a urologist or infectious diseases specialist is warranted if the orchitis does not respond to initial management.

One note of extreme importance is to remember that epididymitis is extremely rare in childhood. Any child who presents with acute scrotal pain has torsion until proved otherwise.

Incarcerated Hernia

Incarcerated hernias can present as an etiology of acute, painful, scrotal swelling. The history is usually consistent with a hernia, the testicle exam is usually unimpressive, the urinalysis typically normal and there is usually no associated voiding symptoms. Nausea and vomiting, a change in bowel habits, and abdominal distension may help to suggest the diagnosis. The abdominal exam will generally confirm the diagnosis. Immediate surgical referral is required if the hernia cannot be reduced.

Fournier’s Gangrene

Fournier’s gangrene is a very uncommon infection of the skin and fascia of the scrotum and perineal tissues. It occurs most frequently in middle aged patients and is usually associated with obesity and diabetes. It is rapidly progressive and requires quick intervention and radical surgical debridement for treatment. The mortality rate has been reported as high as 75 percent, even despite antibiotics and aggressive surgical resection of the necrotic tissues. Although it would be uncommon to see this disease in the general military population, it is not out of the realm of possibilities to see this process in contaminated wounds in a forward-deployed operational setting. The initial treatment is multiple broad-spectrum antibiotics and immediate evacuation to the nearest surgical facility.

Testicular Tumors

The most common solid tumor in males between the ages of fifteen and forty is a germ cell tumor of the testicle. While most testicular tumors will present with a painless nodule found on palpation of the testis, occasionally a patient will present with testicular pain and swelling due to necrosis from the tumor outgrowing its blood supply. The pain may be acute in onset, can be associated with scrotal skin changes and edema, but generally the spermatic cord will be normal and the epididymis is normally positioned and nontender. Often the diagnosis of the solid, intratesticular mass is made on ultrasound. The treatment is immediate radical surgery to remove the entire testicle and spermatic cord. Referral or evacuation at the earliest safe opportunity to a surgical facility capable of performing the surgery is mandatory. These tumors can progress rapidly and patients can die within days after diagnosis if treatment is delayed.

A varicocoele is a collection of dilated veins within the spermatic cord. The exam will reveal a thickened spermatic cord that will engorge with valsalva. The testicle is normal, but with a longstanding varicocoele, especially in an adolescent, atrophy of the testicle may be noted. Approximately fifteen percent of the population will have a varicocoele and most commonly they will present on the left side. If the patient has a right sided varicocoele or one which does not go away with supine positioning, a CT scan of the abdomen and pelvis is needed to rule out a retroperitoneal process causing compression of the venous system. No therapy is required for a varicocoele, unless the patient has progressive atrophy of the testicle. Varicocoeles have been associated with an increased rate of infertility; however, a causal relationship does not exist. Routine referral to a urologist for evaluation is warranted if this becomes an issue for the patient.

Spermatocoeles, Epididymal Cysts, and Hydrocoeles

Spermatocoeles and epididymal cysts are cystic dilations of the epididymis and accessory structures of the testicle. They commonly present as a newly discovered soft mass along the pole of the testicle or the epididymis. They typically transilluminate, have a cystic consistency by palpation, and the remainder of the testicle exam is normal. These are self-limited processes and no surgery is required. A routine ultrasound can be performed to confirm the diagnosis.

Hydrocoeles are another major source of painless scrotal swelling. A hydrocoele is a collection of fluid within the tunica vaginalis surrounding the testicle and cord. The mass will transilluminate easily and may compress or reduce on exam. It may communicate with the abdominal cavity. The acute onset of a hydrocoele requires an ultrasound to confirm the absence of a testicular neoplasm. While this is unlikely, hydrocoeles rarely occur spontaneously as one ages. No therapy is needed for the hydrocoele unless it becomes so large as to become burdensome for the patient.

Acute scrotal swelling has many etiologies, some of which can have disastrous consequences if not diagnosed and treated properly. However, a thorough history and physical will often help distinguish between benign conditions and the acute scrotum. The general consideration with all scrotal swelling is assessing whether the testicle is adequately perfused. When this is in doubt, an ultrasound of the scrotum will answer this question. A prompt diagnosis is often required, especially if torsion of the testicle is considered likely.