Testicular Pain

You may assume that testicular pain can safely be observed until its cause becomes clearer. Some causes are minor or treatable with antibiotics. Testicular torsion can permanently damage a testicle within hours, so sudden pain must be assessed immediately rather than monitored at home.

Sudden testicular pain is an emergency symptom Sudden severe pain in one testicle may be caused by testicular torsion. Torsion occurs when the testicle rotates around the spermatic cord. This interrupts its blood supply and can rapidly cause irreversible damage. The NHS advises immediate A&E assessment for sudden severe pain, pain with nausea or abdominal pain, or pain lasting more than one hour or continuing at rest. Do not wait to see whether pain improves Pain from torsion may begin suddenly, during sleep, during sport, after a minor injury, or without any trigger. It may initially be felt in the lower abdomen or groin rather than directly in the testicle. Do not delay because embarrassment, school, work or travel makes attendance inconvenient. Testicular torsion has several possible features Symptoms may include sudden severe one sided pain, scrotal swelling, nausea or vomiting, and lower abdominal pain. Redness, a testicle sitting higher than usual, a more horizontal testicular position, or marked tenderness can also occur. Not every feature is present. The absence of visible swelling does not safely exclude torsion. Torsion is particularly important in teenagers Torsion is commonest around puberty, but it can occur in newborns, children and adults. Teenagers may delay telling someone because they feel embarrassed or hope the pain will settle. A parent or trusted adult should respond without judgement and arrange immediate hospital care. Young children may report abdominal pain A child may present with lower abdominal pain, vomiting, refusal to walk, an unusual gait, distress when being moved, irritability, or scrotal swelling. The child may not identify the testicle as the source. Unexplained acute abdominal pain in a boy or child with testicles should include consideration of the scrotum. Intermittent torsion can come and go A testicle may twist and then untwist without treatment. This can cause sudden pain that settles, recurrent similar episodes, nausea during attacks, or a temporary change in testicle position. Pain resolution does not prove that the problem was harmless. Intermittent torsion can recur and later remain twisted. Seek urgent assessment after a suspicious episode even if the pain improves. Do not attempt to untwist the testicle Manipulating the scrotum can increase pain, delay surgery, twist the testicle further, or create false reassurance if pain changes. Manual detorsion is a clinician led emergency measure in selected circumstances. It does not replace surgery because the testicle can twist again. Surgery may be needed without waiting for a scan When the clinical pattern strongly suggests torsion, the surgical team may recommend urgent scrotal exploration. The surgeon examines the testicle directly and untwists it when possible. Both testicles are often secured to reduce future twisting. Delaying for ultrasound can be harmful when clinical suspicion is high. Epididymitis is a common alternative cause Epididymitis is inflammation of the epididymis behind the testicle. Possible symptoms include pain that may be sudden or gradual, tender, warm or swollen scrotal tissue, and fluid around the testicle. Burning when passing urine, urinary frequency or urgency, penile discharge, and fever can also occur. It is commonly caused by an STI in younger adults or urinary bacteria in older adults, although the pattern varies. Infection symptoms cannot safely exclude torsion Torsion and infection can both cause pain, swelling, redness, abdominal symptoms and nausea. A urine test or sexual health history cannot by itself exclude torsion. When there is doubt, emergency surgical assessment takes priority. Epididymo orchitis affects more than the epididymis When inflammation extends into the testicle, it is called epididymo orchitis. You may experience increasing swelling, testicular pain, fever, urinary symptoms, discharge, or feeling generally unwell. Antibiotics are used when bacterial infection is likely. The choice depends on age, sexual history, urine findings and local guidance. Sexual health assessment should be respectful If an STI is possible, you may be offered urine testing, urethral or self collected swabs, chlamydia and gonorrhoea testing, HIV and syphilis testing where appropriate, and partner notification support. A diagnosis does not establish when an infection was acquired or prove infidelity. Questions should be confidential, relevant and non judgemental. Complete antibiotic treatment as prescribed Symptoms may begin improving after treatment, but swelling can take longer to settle. Seek reassessment when pain worsens, fever develops or persists, you vomit, you cannot pass urine, the swelling increases, symptoms do not improve as expected, or a lump remains after the infection settles. Persistent swelling needs reassessment because infection may not be the only explanation. Orchitis can follow a viral illness Orchitis means inflammation of the testicle. It may occur with bacterial epididymo orchitis, mumps, other viral infections, or less common inflammatory causes. Mumps related orchitis may follow fever, headache and swelling near the jaw or ear. Vaccination reduces risk but does not remove every possibility. Injury can range from minor to serious Testicular injury may occur during sport, cycling, a fall, assault, a road traffic collision, or work activity. Minor pain may improve with rest and supportive underwear. Urgent assessment is needed for severe pain, rapid swelling, significant bruising, nausea, an abnormal testicle position or persistent tenderness. Trauma does not rule out torsion An injury may trigger torsion, coincide with torsion, or distract attention from torsion. Do not assume a minor knock fully explains sudden severe pain. A trapped hernia can cause scrotal pain An inguinal hernia can descend into the scrotum. A strangulated or obstructed hernia may cause sudden groin or scrotal pain, a hard tender lump, vomiting, and abdominal distension. Inability to pass stool or wind, and darkening skin over the swelling, can also occur. This requires emergency surgical assessment. A kidney stone can cause referred pain A stone moving through the ureter may cause pain that travels from the side or back into the groin, the testicle, or the lower abdomen. Other features may include waves of severe pain, restlessness, nausea, vomiting, blood in urine, and urinary urgency. The testicle itself may appear normal. Fever with possible stone disease requires urgent hospital assessment because infection behind an obstruction can become life threatening. Other pain may be referred from nearby structures Testicular or scrotal pain can also originate from the groin, hip, pelvic floor muscles, lower spine, nerves, prostate, bladder, or abdominal wall. Referred pain is considered only after urgent scrotal causes have been excluded. Varicoceles may produce a dragging ache A varicocele may cause dull discomfort, heaviness, pain after prolonged standing, symptoms during exercise, or relief when lying down. Sudden severe pain is not a typical pattern and requires urgent assessment for another cause. Testicular cancer usually presents with another change Pain alone is not usually the main presentation of testicular cancer. Concern increases when pain occurs with a lump, enlargement, firmness, heaviness, or change in shape or texture. The NHS advises assessment for persistent pain or any associated testicular change. Persistent pain still needs assessment Arrange a review when pain persists, repeatedly returns, affects walking or sleep, or is associated with a lump. The same applies when pain occurs after a previous infection, follows vasectomy or surgery, or is accompanied by urinary or sexual symptoms. Chronic pain may require urology, pain or pelvic health assessment. Examination begins with urgency The clinician may assess pain onset, nausea or vomiting, testicle position, swelling, tenderness and skin colour. Groin hernia, abdominal tenderness, and urinary and neurological symptoms are also assessed. Both sides are usually examined for comparison, and a chaperone should be offered. The cremasteric reflex is not a home test Clinicians may assess whether touching the inner thigh causes the testicle to rise. An absent response can support suspicion of torsion. However, the reflex varies and cannot safely confirm or exclude torsion by itself. Do not ask someone without clinical training to test it. Tests depend on the likely cause Possible investigations include urine dipstick, urine culture, STI testing, blood tests, scrotal ultrasound, imaging for a stone, or immediate surgical exploration. A normal urine test does not exclude torsion. A scan should not delay urgent surgery when the clinical pattern is strongly concerning. Pain relief does not determine the diagnosis Strong pain relief may reduce symptoms from torsion, infection, stones or trauma. Improvement after medicine does not establish that the condition is safe. Continue with the urgent assessment recommended. Fertility may be discussed Some conditions can affect sperm production or testicular function, including severe torsion, bilateral disease, significant infection, mumps orchitis, testicular cancer, or certain treatments. Prompt treatment protects health and may help preserve function.

Testicular pain is assessed in a set order: could the testicle have twisted and lost its blood supply, is there infection or inflammation, is a hernia trapped, has trauma caused internal injury, and is pain being referred from the urinary tract, abdomen or groin. Torsion is excluded first because delay creates the greatest immediate risk.