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MikaRaitanen

Testis Pain

Diagnose and treat testis torsion immediately.
Treat epididymitis with antimicrobials. In adolescents, remember the possibility of a chlamydia infection.
Diagnose varicocele as a cause of prolonged testis pain.
In association with acute abdominal pain, remember to examine the testes.
Vasectomy and inguinal hernia repair are associated with the risk of chronic scrotal pain, of which patients should be informed in advance.

The aetiology of acute testis pain is testis torsion until proven otherwise.
Typical patients are children and adolescents who are not yet sexually active, but testis torsion can also occur in adults.
Pain, which may initially be felt only in the lower abdomen and only later in the scrotum, and unilateral swelling of the scrotum start suddenly.
The testicle may rise into the upper part of the scrotum and lie there horizontally, but in the initial phase, tenderness of the testicle often is the only finding.
Torsion of appendix testis and epididymitis may resemble testis torsion. The differential diagnosis can often be made only in an operation.
Testis torsion should be treated with an urgent operation to untwist the torsion and to fix both testicles in place within the scrotum.

Swelling and tenderness are located in the epididymis, but the testis itself may also be tender. The scrotum is often swollen, reddened and hot.
Symptoms associated with urination are often present: pain, burning and frequency.
The causative agents include bacteria causing urinary tract infections, and in sexually active patients also chlamydiae and sometimes gonococci. In older men retention problems often constitute a predisposing factor.
Epididymitis occurs also before the sexually active age.
In children epididymitis is apparently caused by the passage of sterile or infected urine to the deferent duct. In recurrences, ultrasonography of the urinary tracts is a worthwhile examination for excluding e.g., ectopic ureter. Attention should also be paid to enuresis and difficulties in voiding.
In all age groups manipulation of the urethra, such as prolonged indwelling catheterization and urological interventions, predispose to epididymitis.
Investigations
- CRP
- Chemical urinalysis and urine culture
- Nucleic acid testing for chlamydia and gonorrhoea
The initial treatment in children consists of trimethoprim-sulphamethoxazole or a cephalosporin derivative, and of a fluoroquinolone in other patients. The treatment is adjusted according to sensitivity testing. Long courses of fluoroquinolones should be avoided. Duration of treatment is 2 weeks.
A suspensor to support the scrotum, cool bandages, and NSAIDs relieve pain.

The swelling is located in the testis itself.
Orchitis is very uncommon in countries where mumps has disappeared as a result of vaccinations, but may be associated with epididymitis (epididymo-orchitis).
The differential diagnosis of orchitis and testicular torsion is difficult (refer to hospital urgently if there is the slightest doubt).
Investigations
- Parotitis serology (paired serum samples) from the unvaccinated
Treatment
- Pain relief (see above)

In a young man the symptoms are visible varicose veins on the left side, and sometimes pain as well as decreased fertility.
For more information: see article Enlarged Scrotum or Palpable Mass in Scrotum.

In chronic scrotal (content) pain (CSP or CSCP, respectively), the pain may be felt in a testis, epididymis and/or vas deferens.
A single cause for the pain can rarely be established.
- Of single causes, the most common are pains following vasectomy and inguinal hernia repair.
- About 15% of patients experience scrotal pain 6 months after vasectomy.
- In about 1% the pain disturbs daily life.
- Pain occurs less frequently when non-scalpel technique is used.
- After inguinal hernia repair, about 10% of patients have chronic pain, which is why only symptomatic inguinal hernias are operated.
Ultrasound examination of the groins and the scrotum is recommended, to exclude, for example, inguinal hernia and testicular cancer.
Multiprofessional treatment provided by, for example, an outpatient pain clinic may be beneficial.
Sometimes pain following vasectomy can be relieved by reconnecting the vasa deferentia (vasovasostomy).
If spermatic cord anaesthesia block (SCAB) relieves the pain, microsurgical denervation of the spermatic cord may be beneficial.

Hetta DF, Mahran AM, Kamal EE. Pulsed Radiofrequency Treatment for Chronic Post-Surgical Orchialgia: A Double-Blind, Sham-Controlled, Randomized Trial: Three-Month Results. Pain Physician 2018;21(2):199-205. [PubMed]
Tantawy SA, Kamel DM, Abdelbasset WK. Does transcutaneous electrical nerve stimulation reduce pain and improve quality of life in patients with idiopathic chronic orchialgia? A randomized controlled trial. J Pain Res 2018;(11):77-82. [PubMed]