Information
Editors
Testis Pain
Essentials
- 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.
Testis torsion
- 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.
Epididymitis
- 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.
Orchitis
- 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
Chronic scrotal pain
- 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.
References
- 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]