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Sunday, August 17, 2025

Testicle pain


Introduction

Testicle pain, also called orchialgia or scrotal pain, refers to discomfort, aching, or sharp pain localized to one or both testicles. It may develop suddenly (acute) or persist over weeks to months (chronic). Because the testicles are highly sensitive and richly innervated, even minor injuries or inflammation can cause significant discomfort. Importantly, acute testicular pain is a medical emergency until proven otherwise, as conditions such as testicular torsion can lead to irreversible loss of the testicle if not treated promptly.

This overview discusses the causes, diagnostic approach, and treatment options for testicular pain, with emphasis on pharmacological management including generic drug names and typical dosing.

Causes of Testicle Pain

1. Emergencies

  • Testicular torsion

    • Twisting of the spermatic cord cuts off blood supply.

    • Sudden, severe unilateral pain, swelling, nausea, vomiting.

    • Requires urgent surgical intervention within 6 hours to salvage the testicle.

  • Incarcerated inguinal hernia

    • Strangulated bowel in the inguinal canal can cause severe scrotal pain.

    • Requires urgent surgical repair.

2. Infections

  • Epididymitis (most common cause in young men)

    • Inflammation of the epididymis, often due to sexually transmitted infections (STIs) like Chlamydia trachomatis or Neisseria gonorrhoeae in men <35 years.

    • In older men, usually due to urinary tract pathogens (E. coli).

    • Symptoms: gradual pain, swelling, fever, dysuria.

  • Orchitis

    • Inflammation of the testicle itself.

    • Viral (e.g., mumps) or bacterial (usually secondary to epididymitis).

    • May cause infertility if bilateral.

3. Trauma

  • Direct injury to the scrotum (sports, accidents).

  • May result in contusion, hematoma, or rupture.

  • Requires ultrasound to assess severity.

4. Chronic Causes

  • Varicocele: dilated scrotal veins, dull aching pain worse with standing.

  • Hydrocele: fluid collection around testicle, usually painless but may cause heaviness.

  • Spermatocele: benign cyst causing mild discomfort.

  • Chronic orchialgia: long-standing pain >3 months, often idiopathic.

5. Referred Pain

  • From kidney stones, inguinal hernia, lower back disorders, or nerve compression.

6. Cancer

  • Testicular tumors usually present as a painless lump, but sometimes pain or discomfort occurs.

  • Requires urgent referral and scrotal ultrasound.

Clinical Presentation

  • Acute pain: torsion, trauma, infection.

  • Chronic pain: varicocele, hydrocele, idiopathic.

  • Associated symptoms:

    • Fever and urinary symptoms → infection.

    • Nausea and vomiting → torsion.

    • Painless mass → cancer.

Diagnostic Evaluation

History

  • Onset (sudden vs gradual).

  • Trauma history.

  • Sexual history (risk of STI).

  • Urinary symptoms.

  • Associated systemic symptoms (fever, nausea).

Physical Examination

  • Inspection: swelling, redness, asymmetry.

  • Palpation: tenderness, masses, fluctuation.

  • Cremasteric reflex: absent in torsion.

  • Prehn’s sign: pain relief when elevating scrotum suggests epididymitis (not reliable but often cited).

Investigations

  • Scrotal ultrasound with Doppler: key test to assess blood flow and exclude torsion.

  • Urinalysis and urine culture: check for infection.

  • Urethral swab or urine NAAT: for Chlamydia and Gonorrhea.

  • Blood tests: CBC, CRP, ESR.

  • Tumor markers (AFP, β-hCG, LDH) if cancer suspected.

Treatment Strategies

1. General Supportive Measures

  • Rest and scrotal elevation.

  • Ice packs for acute swelling.

  • Supportive underwear.

  • Analgesics for pain relief.

2. Pharmacological Treatment

Analgesia

  • Paracetamol (acetaminophen): 500–1000 mg every 6 hours as needed (max 4 g/day).

  • NSAIDs:

    • Ibuprofen: 200–400 mg every 6–8 hours as needed (max 2400 mg/day).

    • Naproxen: 250–500 mg twice daily.

    • Diclofenac: 50 mg orally twice to three times daily.

Epididymitis/Orchitis

  • In men <35 years (likely STI-related)

    • Ceftriaxone: 500 mg IM single dose, plus

    • Doxycycline: 100 mg orally twice daily for 10 days.

  • In men >35 years or with urinary pathogens

    • Levofloxacin: 500 mg orally once daily for 10 days, or

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

  • Pain relief: NSAIDs, scrotal support.

Mumps Orchitis (Viral)

  • Supportive only: bed rest, ice packs, NSAIDs or paracetamol.

  • Corticosteroids (e.g., prednisone 40–60 mg daily tapering over 7 days) sometimes used for severe cases.

3. Surgical Treatment

  • Testicular torsion: urgent surgical detorsion and fixation (orchiopexy). If non-viable → orchiectomy.

  • Incarcerated hernia: emergency surgical repair.

  • Abscess: incision and drainage.

  • Testicular cancer: radical inguinal orchiectomy.

  • Varicocele: surgical ligation or embolization if symptomatic.

4. Chronic Orchialgia

  • Rule out underlying cause.

  • Neuropathic pain agents may be considered:

    • Amitriptyline: 10–25 mg at night.

    • Gabapentin: 300–900 mg/day in divided doses.

  • Nerve block or microsurgical denervation in refractory cases.

Red Flags (Require Urgent Referral)

  • Sudden severe testicular pain (possible torsion).

  • Severe swelling, fever, and systemic illness (infection/abscess).

  • Palpable mass suspicious for cancer.

  • Trauma with persistent pain or swelling.

Prognosis

  • Torsion: salvage possible if treated within 6 hours; delayed diagnosis often leads to loss of testicle.

  • Epididymitis/orchitis: good recovery with antibiotics; untreated may cause infertility.

  • Varicocele and hydrocele: benign but may affect fertility if untreated.

  • Cancer: excellent prognosis if detected early.

Summary of Key Treatments with Doses

  • Paracetamol: 500–1000 mg PO q6h (max 4 g/day).

  • Ibuprofen: 200–400 mg PO q6–8h.

  • Naproxen: 250–500 mg PO BID.

  • Diclofenac: 50 mg PO BID–TID.

  • Ceftriaxone: 500 mg IM single dose (STI-related epididymitis).

  • Doxycycline: 100 mg PO BID × 10 days.

  • Levofloxacin: 500 mg PO daily × 10 days (older men/urinary pathogens).

  • Ofloxacin: 300 mg PO BID × 10 days.

  • Prednisone: 40–60 mg PO daily taper (severe viral orchitis).

  • Amitriptyline: 10–25 mg PO nightly (chronic orchialgia).

  • Gabapentin: 300–900 mg/day PO (chronic orchialgia).




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