Pain in testicles

Testicular pain, also referred to as scrotal pain, is a symptom that can range from mild discomfort to severe and debilitating pain. It may be acute (sudden and severe in onset) or chronic (lasting more than three months). Testicular pain often raises significant concern due to the sensitivity of the area and the potential for serious underlying causes, including testicular torsion, infections, trauma, tumors, or referred pain from adjacent structures. A thorough evaluation is essential, as some causes, such as torsion, require urgent surgical intervention to prevent permanent damage or loss of the testicle.

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Causes of Testicular Pain

1. Acute Causes

• Testicular torsion:

  • A urological emergency where the spermatic cord twists, cutting off blood supply to the testicle.

  • Presents with sudden, severe unilateral pain, swelling, nausea, and vomiting.

  • Must be treated surgically within 6 hours to save the testicle.

• Epididymitis and orchitis:

  • Infections of the epididymis or testicle, commonly caused by bacteria such as Chlamydia trachomatis, Neisseria gonorrhoeae, or E. coli.

  • Pain is usually gradual, with swelling, redness, and sometimes fever and urinary symptoms.

• Trauma:

  • Direct injury may cause contusion, hematoma, or testicular rupture.

  • Severe trauma can compromise blood supply and fertility.

• Torsion of testicular appendage:

  • A remnant structure that can twist and cause pain.

  • Less severe than testicular torsion but may mimic its presentation.

2. Chronic Causes

• Varicocele:

  • Enlargement of the pampiniform plexus veins in the scrotum.

  • Causes a dull, aching pain, worse with standing or exertion.

• Hydrocele:

  • Fluid accumulation around the testicle.

  • Usually painless but can cause a feeling of heaviness or discomfort.

• Inguinal hernia:

  • Herniation of bowel or fat into the scrotum can cause testicular discomfort.

• Testicular tumor:

  • Typically presents as a painless lump, but occasionally causes discomfort or dull pain.

• Nerve-related causes:

  • Referred pain from kidney stones, spinal nerve compression, or pelvic floor dysfunction.

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Symptoms Associated with Testicular Pain

• Local swelling, redness, or warmth.

• Hard lump or mass in the testicle.

• Urinary symptoms (burning, frequency, urgency).

• Systemic symptoms such as fever, chills, nausea, or vomiting.

• Pain radiating to groin, abdomen, or lower back.

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Diagnosis

1. History and Examination

• Onset, duration, and severity of pain.

• History of trauma, infection, or prior episodes.

• Associated symptoms such as fever or urinary complaints.

• Physical exam: palpation of the testicles, assessment of cremasteric reflex, checking for swelling, tenderness, lumps, or hernia.

2. Investigations

• Ultrasound with Doppler: gold standard for assessing testicular torsion and blood flow.

• Urine analysis and culture: to detect urinary tract infection or sexually transmitted infections.

• Blood tests: CBC, CRP, tumor markers (AFP, β-hCG, LDH) if malignancy suspected.

• Scrotal exploration: sometimes required urgently in suspected torsion.

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Treatment of Testicular Pain

1. Emergency Treatment

• Testicular torsion:

  • Immediate surgical detorsion and orchiopexy (fixation of the testicle).

  • Manual detorsion may be attempted as a temporary measure, but surgery is definitive.

• Severe trauma/rupture:

  • Requires surgical repair or orchiectomy if irreparable.

2. Infectious Causes

• Epididymitis/orchitis:

  • Antibiotics:

    • For sexually transmitted infections (STIs):

      • Ceftriaxone (500 mg IM single dose) + Doxycycline (100 mg orally twice daily for 7 days).

    • For non-STI causes (e.g., E. coli):

      • Levofloxacin (500 mg orally once daily for 10 days) or Ofloxacin (300 mg orally twice daily for 10 days).

  • Analgesics: Ibuprofen 400 mg every 6–8 hours as needed.

  • Scrotal elevation and rest.

3. Chronic and Non-emergency Causes

• Varicocele:

  • Managed with analgesics (NSAIDs like ibuprofen or naproxen).

  • Surgical ligation or embolization if persistent pain or infertility.

• Hydrocele:

  • Aspiration or surgical hydrocelectomy if symptomatic.

• Testicular cancer:

  • Orchiectomy followed by staging and further oncological management (chemotherapy, radiotherapy).

• Inguinal hernia:

  • Surgical repair if painful or complicated.

4. General Supportive Measures

• Rest and limitation of strenuous activity.

• Scrotal support (tight underwear or jockstrap).

• Cold compresses for acute swelling.

• Warm baths for chronic discomfort.

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Pharmacological Management (Generic Names and Doses)

• NSAIDs (pain relief):

  • Ibuprofen: 400 mg orally every 6–8 hours (max 3200 mg/day).

  • Naproxen: 500 mg orally, then 250 mg every 6–8 hours as needed.

• Antibiotics for infections:

  • Ceftriaxone: 500 mg IM single dose.

  • Doxycycline: 100 mg orally twice daily for 7 days.

  • Levofloxacin: 500 mg orally once daily for 10 days.

  • Ofloxacin: 300 mg orally twice daily for 10 days.

• Adjuncts:

  • Acetaminophen (paracetamol): 500–1000 mg every 6 hours (max 4 g/day) for pain/fever.

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When to Seek Urgent Medical Help

• Sudden, severe testicular pain (possible torsion).

• Persistent pain not relieved by rest or analgesics.

• Associated fever, nausea, or vomiting.

• Detection of a hard lump in the testicle.

• Trauma with swelling or discoloration of the scrotum.