Scrotal pain

Revise the causes and presentation of scrotal pain and when to refer. By GP Dr Lizzie Croton

Epididymitis with or without orchitis is managed with analgesia, scrotal support and antibiotics (Photograph: SPL)
Epididymitis with or without orchitis is managed with analgesia, scrotal support and antibiotics (Photograph: SPL)

Scrotal pain may be acute, subacute or chronic (lasting more than three months). The patient may complain of pain in one or both testicles or in surrounding structures (epididymus/spermatic cord).

1. Presentation and causes

Testicular torsion usually occurs between the ages of seven and 12 years, and 2% of cases are bilateral. It is also common in adolescent boys. Typically there is sudden, severe pain in one testis that may occur during physical activity. Nausea and vomiting and lower abdominal pain may be present.

Examination may reveal a swollen, tender testis retracted upwards. The epididymus may be felt anterior to the testis as opposed to its normal posterior position.

Torsion of a testicular or epididymal appendage is also most common between the ages of seven and 12. Such cases are far less likely to present with systemic symptoms and examination may reveal localised tenderness on the upper pole of the testes. There may be a tender nodule with bluish discolouration over the affected area (the blue dot sign).

Epididymitis is typified by pain and swelling over the epididymus. It is often associated with symptoms of UTI and in more than half of cases the testicle is also involved (epididymo-orchitis). Onset is usually gradual, with varying degrees of pain.

Fournier's gangrene is a rare condition caused in most cases by a mixture of aerobic and anaerobic bacteria. It is a rapidly spreading necrotising soft tissue infection of the perineum and genitalia. Most patients are in their sixties or older with other comorbidities.

If epididymitis persists for more than six weeks, it may become chronic. Here, inflammation and pain persist in the epididymus. Urine culture may be sterile.

Post-vasectomy pain syndrome (PVPS) is a chronic and debilitating condition that can develop immediately or many years after a vasectomy. Incidence is thought to be around 15%, causing pain in the genitals and groin. Symptoms vary in severity and situation, and may be present continuously or only when engaging in physical or sexual activity.

There are various theories as to the mechanisms of pain, including epididymal congestion, fibrosis from scar tissue and sperm granulomas. In 25% of cases of chronic scrotal pain, the cause is never determined.

Other causes include renal colic - pain may radiate from the loin area into the groin because of the embryological link between the urinary tract and genital system. Gilmore's groin strain is a chronic groin pain syndrome found in athletes, with pain characteristically following sporting activity.

Typical examination findings are that of a dilated superficial inguinal ring which can be palpated when the scrotum is inverted with the little finger.

Causes of scrotal pain

Acute

  • Testicular torsion.
  • Torsion of testicular appendage.
  • Epididymitis with/without orchitis.
  • Fournier's gangrene.
  • Injury.
  • Strangulated inguinal hernia.
  • Infected sebaceous cyst of scrotal skin.

Chronic

  • Chronic epididymitis.
  • PVPS.
  • Secondary to hydrocoele/varicocoele.
  • Inguinal hernia.
  • Indeterminate cause.

Other causes

  • Referred pain from renal colic.
  • Gilmore's groin strain.

2. Examination

When examining the male genitalia, it is imperative to examine the inguinal canal with the patient standing to check for hernias, which may cause acute testicular pain if they become strangulated and irreducible. When examining the scrotum, it is important to look at the posterior surface so as not to miss lesions of the scrotal skin.

3. Management

Testicular torsion is a surgical emergency. With prompt treatment within six hours, the testis has a 90% chance of survival. After 12 hours, the rate decreases to 50% and the testis is usually unsalvageable after 24 hours.

Treatment involves untwisting the affected testicle surgically with fixation of both testes within the scrotum to prevent recurrence. Non-viable testes are removed to prevent gangrenous infection. A suspected torsion of the testicular appendage usually requires scrotal exploration to rule out a coexistent testicular torsion.

Fournier's gangrene is a urological emergency requiring admission and surgical debridement of affected tissue, with IV antibiotics. The mortality rate approaches 78% if sepsis has developed.

Referral criteria

Emergency

  • Testicular torsion.
  • Torsion of testicular appendage.
  • Suspected Fournier's gangrene.
  • Strangulated inguinal hernia.

Urgent

  • Suspected testicular tumour.

Elective

  • Symptomatic non-strangulated inguinal hernia.
  • Non-resolving Gilmore's groin strain.
  • Disruptive PVPS.

Epididymitis with or without orchitis is managed with appropriate analgesia, scrotal support and antibiotics. In sexually active men, Chlamydia trachomatis is the most frequent causative organism, followed by Escherichia coli and Neisseria gonorrhoeae. In older men, epididymitis is more commonly due to urinary tract obstruction, such as BPH, and E coli is the usual causative organism.

It is important to take a sexual history from the patient and offer a full screen for STIs.

Appropriate blind therapy for suspected chlamydia or other non-gonococcal organisms would be doxycycline 100mg twice daily for 10-14 days. With suspected enteric organisms, ciprofloxacin 500mg twice daily for 10 days is effective.

In PVPS, treatment options are targeted towards the suspected cause. Possible options include scar tissue excision, removal of spermatic granulomas and surgical removal of the epididymus. Nerve blocks and corticosteroid injections are less invasive options.

The management of Gilmore's groin strain may be conservative in milder cases, with stretches coupled with a period of rest. Definitive treatment consists of surgical management followed by a structured rehabilitation.

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  • Dr Croton is a GP in Birmingham

Further reading

Dr Lizzie Croton recommends

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