Makindo Medical Notes

⚠️ 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

🔍 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.