Acute Scrotal Pain in Adults and Adolescents

Background

• Acute scrotal pain refers to the sudden onset of testicular pain, with or without swelling, whereas chronic scrotal pain typically refers to constant or intermittent pain that lasts ≥ 3 months and interferes with daily activities.
• Acute scrotal pain may be caused by vascular disruptions (ischemia) to the scrotal tissue, infection or inflammation (either local or systemic), trauma involving the genitourinary tract, or other scrotal or nonscrotal causes.
  • Common scrotal causes include testicular torsion, acute epididymitis, hydrocele, varicocele, spermatocele, and scrotal trauma.
  • Common nonscrotal causes include inguinal hernia and kidney colic.
• Acute scrotal pain is reported to be a relatively common presentation in emergency and acute care settings, and it is reported to account for about 1% of emergency department visits.
• Acute scrotal pain is considered an emergency when it is due to causes requiring prompt medical or surgical intervention, such as testicular torsion (which may result in loss of testicular function if the blood supply to the testicles is not restored in 6 hours or less), Fournier gangrene (which, albeit infrequently occurring, has a reportedly high mortality rate), traumatic testicular rupture, incarcerated or strangulated hernia, and testicular cancer.

Evaluation

• Acute scrotal pain requires careful history and physical examination to determine the underlying cause of pain.
• Many causes have similar or overlapping features at presentation.
  • Sudden onset of pain may occur in testicular torsion, Fournier gangrene, and, less often, in acute epididymitis (which is typically characterized by a more gradual onset of pain).
  • Testicular or scrotal swelling may occur in testicular torsion, acute epididymitis, mumps orchitis, Fournier gangrene, and acute idiopathic scrotal edema.
  • A palpable testicular mass may occur in testicular cancer, hydrocele, varicocele, and inguinal hernia.
  • Systemic or extratesticular features such as nausea and vomiting may be present in testicular torsion and kidney colic.

Table 1. Clinical Presentation of Causes of Acute Scrotal Pain

• Prompt diagnosis of the underlying cause is necessary to rule out causes that represent a medical emergency and require immediate treatment. In particular, testicular torsion should be considered for all patients presenting with acute scrotal pain since prompt assessment and treatment are essential to preserve the testicular function.
• The diagnostic approach may vary based on suspected cause, including:
  • vascular disruptions such as testicular torsion, torsion of testicular appendage, or segmental testicular infarction
  • infection or inflammation such as acute epididymitis, Fournier gangrene, Henoch-Schonlein purpura, Behcet syndrome, or polyarteritis nodosa
  • trauma
  • other urologic or scrotal causes such as testicular cancer, hydrocele, varicocele, or spermatocele
  • nonscrotal causes such as incarcerated or strangulated hernia or kidney colic

Table 2. Summary of Findings on Diagnostic Testing of Causes of Acute Scrotal Pain

Management

• Management of acute scrotal pain mainly consists of treating the underlying cause of pain.
• The following causes of acute scrotal pain typically require emergent or urgent management, which may include surgical exploration or repair, referral to specialist (urologist), and/or initiation of antimicrobial therapy.
  • For testicular torsion, management options include immediate scrotal exploration, detorsion, and orchidopexy. Torsion of testicular appendage may not necessarily require surgical intervention.
  • For traumatic testicular rupture, management options include surgical exploration, orchidopexy, orchiectomy, and reconstruction; conservative management (including scrotal support, analgesics, and ice packs) may be appropriate for small hematocele (< 3 times the size of contralateral testis) and testicular dislocation.
  • For acute epididymitis (and acute epididymo-orchitis), treatment includes antibiotic therapy.
  • For Fournier gangrene, mainstays of care are prompt and complete surgical debridement combined with immediate and aggressive antimicrobial therapy.
  • For incarcerated or strangulated hernia, urgent surgical referral is required; however, small, reducible hernia may not require urgent surgery.
  • For testicular cancer, prompt urologic referral is required; management depends on type of testicular cancer and clinical stage, and options include surgery, chemotherapy, radiation therapy, or surveillance.
• Other causes of acute scrotal pain do not typically require urgent treatment and may be managed with surgical exploration or repair, referral to specialist (urologist), initiation of medical therapy, or surveillance.
  • For segmental testicular infarction, management was historically based on surgery, but conservative management has been reported in patients with high certainty of diagnosis (once testicular cancer has been ruled out).
  • For Behcet syndrome, management depends on the affected organs, the severity of the disease, and other patient characteristics; it may include topical treatment (including local corticosteroids) or systemic therapies (such as colchicine, cyclosporine A, azathioprine, interferon alfa, and tumor necrosis factor alpha antagonists).
  • For hydrocele, management depends on the presence or absence of symptoms and includes watchful waiting, surgery, or aspiration and sclerotherapy.
  • For varicocele, surgical management is controversial; considerations for surgery include recurrence, size of varicocele, and presence of symptoms.
  • For spermatocele, intervention is likely not required if asymptomatic; if symptomatic, referral for consideration of surgical excision may be appropriate.