⚠️ Scrotal pain and swelling require urgent assessment. - Testicular torsion 🚨 is a surgical emergency; salvage rates fall steeply beyond 6 hours. - Testicular tumours 🎗️ are classically painless, but need rapid referral for early cure.

📖 Introduction

Scrotal pain is a common yet diagnostically challenging presentation, spanning benign self-limiting causes to life-threatening emergencies.
Lumps/swelling may arise from the testis, epididymis, spermatic cord, or adjacent structures; they can also reflect referred pain from the abdomen or spine.
Early recognition, particularly of torsion and tumour, is crucial to preserve fertility, prevent necrosis, and avoid missed cancers.

🔬 Pathophysiology

Testicular torsion: Twisting of the spermatic cord → venous outflow obstruction → arterial compromise → ischaemia → infarction. Necrosis develops within hours.
Epididymo-orchitis: Bacterial or viral inflammation causes neutrophilic infiltration, swelling, fever, and tenderness. Pathogens vary with age (STIs in young men, coliforms in older).
Hydrocele / Cyst: Imbalance of fluid secretion and absorption in tunica vaginalis or epididymal ducts → fluctuant, transilluminating swelling.
Tumours: Malignant germ cell proliferation → firm, intratesticular mass, often painless.
Other causes: Trauma (haematoma/rupture), vascular (infarction, sickle cell), congenital remnants (torsion of hydatid), or referred pain (renal colic, hernia).

🩺 Clinical Assessment

History: Onset (sudden vs gradual), severity, urinary/STI history, trauma, systemic symptoms.
Examination: Inspect for swelling, erythema, testicular lie. Palpate for tenderness, lump consistency, transillumination, reducibility of hernia.
Cremasteric reflex: Most sensitive sign for torsion (absent in torsion, preserved in infection).
Always examine abdomen and groin — hernia and renal colic can mimic testicular pathology.

⚡ Causes of Scrotal Pain & Swelling


Differential	Key Clinical Features	Investigations	Management
Testicular Torsion ⏱️	Sudden severe pain, high-riding testis, absent cremasteric reflex, nausea/vomiting.	Urgent Doppler US if equivocal — but do not delay surgery.	Immediate surgical detorsion + bilateral orchiopexy; orchidectomy if non-viable.
Epididymo-orchitis 🦠	Gradual onset pain, tender swelling, fever, LUTS, urethral discharge.	Urinalysis, urine culture, STI NAAT, US (↑ flow).	Antibiotics (STI: ceftriaxone + doxycycline; coliform: quinolone/Co-amoxiclav), NSAIDs, scrotal support.
Hydrocele 💧	Painless swelling, transilluminates, fluctuant.	USS to exclude underlying tumour.	Reassure; surgery if large or symptomatic.
Torted Hydatid of Morgagni 🌱	Upper pole pain, “blue dot sign”.	USS to exclude torsion.	Supportive once torsion excluded.
Varicocele 🩸	Dull ache, “bag of worms”, worse on standing, may affect fertility.	USS with Doppler.	Ligation or embolisation if symptomatic/fertility concern.
Testicular Tumour 🎗️	Painless firm mass, heaviness, ± gynaecomastia.	USS (solid mass), AFP, β-hCG, LDH, CT for staging.	Radical inguinal orchidectomy ± chemo/radiotherapy. Never biopsy trans-scrotally.
Trauma 🥊	Acute pain, bruising, swelling; history of injury.	USS for rupture/haematoma.	Supportive (ice, NSAIDs) or surgical exploration if rupture suspected.
Other causes	Hernia (groin bulge), renal colic (loin-to-groin pain), vascular (sickle cell, vasculitis).	Clinical ± targeted imaging.	Treat underlying pathology.

🔍 Investigations

Scrotal ultrasound with Doppler: First-line in uncertain cases.
Urinalysis & culture: Infection assessment.
STI screen (NAAT): In young, sexually active men.
Tumour markers (AFP, β-hCG, LDH): If mass suspected.
CT / CXR: Staging in confirmed malignancy.
Rule: Do not delay urgent torsion exploration for imaging if suspicion is high.

💊 Management Principles

Surgical: torsion, hernia, cancer, large hydroceles, symptomatic varicoceles, trauma with rupture.
Medical: antibiotics for infection, analgesia (NSAIDs, paracetamol), STI-directed therapy.
Supportive: scrotal elevation, rest, hydration, reassurance for benign lesions.
Follow-up: oncological surveillance for tumours, fertility counselling if bilateral pathology.

🚨 Red Flags

Torsion: assume until proven otherwise in acute severe pain.
Testicular cancer: any painless lump = urgent urology referral (2-week wait, UK).
Strangulated hernia: irreducible tender swelling + systemic upset requires urgent surgery.

📚 Summary

👉 Scrotal pain has a broad differential but always exclude torsion first. 👉 Painless masses can be sinister — ultrasound and early referral are essential. 👉 Early recognition prevents testicular loss, infertility, or missed cancer diagnoses.

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Scrotal/testicular pain/lump/swelling ⚠️