Scrotal pain

Probability diagnosis

Trauma including haematoma, haematocele

Torsion of a testicular appendage

Varicocele

Epididymitis

Post vasectomy

Serious disorders not to be missed

Vascular:

• testicular torsion

Infection:

• acute epididymo-orchitis/orchitis

• fulminating necrotising cellulitis (Fournier’s gangrene)

• psoas abscess

• tuberculosis

Cancer:

• testicular neoplasm

Other:

• strangulated inguinoscrotal hernia

• acute hydrocele

Pitfalls (often missed)

Referred pain (e.g. spine, ureteric colic, abdominal aorta)

Rarities:

• idiopathic scrotal oedema

• polyarteritis nodosa

• filariasis

Key history

Determine any pre-existing predisposing factors such as lumps or history of trauma. Check travel history, sexual history.

Key examination

• Examine and contrast both sides of the scrotum, including the inguinal and femoral hernial orifices, the spermatic cord, testis and epididymis

• Examine the patient standing and supine

• A painful testis should be elevated gently to determine if the pain improves

Key investigations

Useful investigations include:

• FBE

• urine analysis, microscopy and culture

• Chlamydia detection tests

• ultrasound

• technetium-99m scan.

Diagnostic tips

• Torsion of the testis is the most common cause of acute scrotal pain in infancy and childhood.

• Think of it with lower abdominal pain and/or vomiting.

• A varicocele can cause testicular discomfort—examine the patient in the standing position.

Red flags:

• sudden onset pain

• non-reductible hernia

• erythema of scrotum or perineum

• systemic vascular symptoms, e.g. hypotension, pallor.