Overview
Acute Scrotal Pain
Quick Reference
Critical Alerts
- Testicular torsion is a surgical emergency: 4-6 hour window for salvage
- High-riding, horizontal testicle = Torsion until proven otherwise
- Absent cremasteric reflex supports torsion
- Do NOT delay surgery for imaging if torsion highly suspected
- Doppler ultrasound is first-line imaging: If diagnosis uncertain
- Pain >6 hours does not exclude torsion: Still consider surgery
Torsion vs Epididymitis
| Feature | Torsion | Epididymitis |
|---|---|---|
| Age | Peak 12-18 years | Peak 18-35 years |
| Onset | Sudden, severe | Gradual |
| Position | High-riding, horizontal | Normal |
| Cremasteric reflex | Absent | Present |
| Prehn sign | Pain NOT relieved | Pain relieved with elevation |
| Doppler | Absent/Decreased flow | Increased flow |
Emergency Treatments
| Condition | Treatment |
|---|---|
| Testicular torsion | Emergent surgery (manual detorsion if delay) |
| Epididymitis | Antibiotics, supportive care |
| Torsion of appendix testis | Supportive care, NSAIDs |
| Fournier's gangrene | Emergent surgery, broad antibiotics |
Definition
Overview
Acute scrotal pain is a common urological emergency. The critical concern is testicular torsion, which causes ischemia and requires emergent surgical detorsion within 4-6 hours for maximal salvage. Other causes include epididymitis, torsion of testicular appendages, trauma, and incarcerated hernia. Doppler ultrasound is the imaging modality of choice when diagnosis is uncertain.
Classification
By Cause:
| Category | Examples |
|---|---|
| Vascular | Testicular torsion |
| Infectious | Epididymitis, orchitis |
| Appendage | Torsion of appendix testis |
| Trauma | Testicular rupture, hematoma |
| Hernia | Incarcerated inguinal hernia |
| Other | Varicocele, hydrocele, tumor |
Epidemiology
- Testicular torsion: 1 in 4,000 males under 25 years
- Peak age: 12-18 years (and neonates)
- Epididymitis: More common in sexually active adults
Anatomy
Testicle:
- Hangs vertically, attached by spermatic cord
- Covered by tunica vaginalis
Bell-Clapper Deformity:
- High attachment of tunica vaginalis
- Testicle free to rotate within tunica
- Present bilaterally; predisposes to torsion
Clinical Presentation
Testicular Torsion
| Finding | Description |
|---|---|
| Age | Peak 12-18 years |
| Onset | Sudden, severe pain |
| Nausea/Vomiting | Common |
| Position | High-riding, horizontal lie |
| Cremasteric reflex | Absent |
| Prehn sign | Pain not relieved by elevation |
| Prior episodes | "Intermittent torsion" |
Epididymitis
| Finding | Description |
|---|---|
| Age | 18-35 years most common |
| Onset | Gradual (hours to days) |
| Dysuria | May be present |
| Urethral discharge | Possible |
| Position | Normal |
| Cremasteric reflex | Present |
| Prehn sign | Pain may improve with elevation |
| Fever | May be present |
Torsion of Appendix Testis
| Finding | Description |
|---|---|
| Age | Prepubertal (7-14 years) |
| Pain | Localized to upper pole |
| Blue dot sign | Visible through scrotal skin |
| Cremasteric reflex | Present |
| Testis | Normal position |
History
Key Questions:
Physical Examination
| Assessment | Finding |
|---|---|
| Inspection | Swelling, erythema, position |
| High-riding testicle | Torsion |
| Horizontal lie | Torsion |
| Cremasteric reflex | Stroke inner thigh → Testicle rises (absent in torsion) |
| Prehn sign | Elevation relieves pain (epididymitis) |
| Blue dot sign | Torsed appendix |
| Epididymal tenderness | Epididymitis |
| Urethral discharge | STI-related epididymitis |
Onset and duration of pain
Common presentation.
Prior similar episodes (intermittent torsion)
Common presentation.
Nausea, vomiting
Common presentation.
Dysuria, urethral discharge
Common presentation.
Trauma
Common presentation.
Sexual history
Common presentation.
Prior surgery (orchiopexy)
Common presentation.
Red Flags
Torsion Indicators
| Finding | Significance |
|---|---|
| Sudden onset severe pain | Torsion |
| High-riding, horizontal testicle | Torsion |
| Absent cremasteric reflex | Torsion |
| Nausea/Vomiting | Torsion |
| under 6 hours from onset | Best salvage window |
Fournier's Gangrene
| Finding | Action |
|---|---|
| Crepitus, necrosis, severe systemic illness | Emergent surgical debridement |
Diagnostic Approach
Clinical Decision
If High Clinical Suspicion for Torsion:
- Do NOT delay for imaging: Take to OR immediately
If Uncertain:
- Doppler ultrasound
Doppler Ultrasound
| Finding | Interpretation |
|---|---|
| Absent or decreased blood flow | Torsion |
| Increased blood flow | Epididymitis/Orchitis |
| Appendage with absent flow | Appendix torsion |
| Heterogeneous echotexture | Hematoma, tumor |
Sensitivity for Torsion: 88-100%
Laboratory
| Test | Indication |
|---|---|
| Urinalysis | Epididymitis (pyuria, bacteriuria) |
| Urine culture | Epididymitis |
| STI testing (GC/Chlamydia NAAT) | Sexually active |
| CBC | Infection |
| Beta-hCG | If tumor suspected |
Treatment
Testicular Torsion
Emergent Surgical Exploration:
- Detorsion and orchiopexy
- Bilateral orchiopexy (bell-clapper bilateral)
- If non-viable → Orchiectomy
Manual Detorsion (If Surgical Delay):
| Technique | Notes |
|---|---|
| "Open the book" | Medial to lateral rotation (right testicle counterclockwise, left clockwise) |
| Pain relief | Successful detorsion |
| Multiple rotations may be needed | 360-720° typical |
| Urology still needed | Orchiopexy required regardless |
Time to Salvage:
| Duration | Salvage Rate |
|---|---|
| under 6 hours | 90-100% |
| 6-12 hours | 50% |
| 12-24 hours | 10-20% |
| >4 hours | under 10% |
Epididymitis
Antibiotic Therapy:
| Population | Regimen |
|---|---|
| under 35 years, sexually active | Ceftriaxone 500 mg IM × 1 + Doxycycline 100 mg BID × 10 days |
| >5 years or not sexually active | Levofloxacin 500 mg daily × 10 days |
Supportive Care:
| Intervention | Details |
|---|---|
| Scrotal elevation | Support |
| Ice | 20 min on/off |
| NSAIDs | Pain relief |
| Activity restriction |
Torsion of Appendix Testis
| Intervention | Details |
|---|---|
| Conservative management | Self-limited (7-10 days) |
| NSAIDs | Pain relief |
| Scrotal support | |
| Follow-up | If not improving |
Fournier's Gangrene
| Intervention | Details |
|---|---|
| Emergent surgical debridement | Life-saving |
| Broad-spectrum antibiotics | Gram-positive, Gram-negative, anaerobes |
| ICU admission | Often required |
Disposition
Discharge Criteria (Epididymitis)
- Diagnosis confirmed, torsion excluded
- Antibiotics prescribed
- Pain controlled
- Follow-up arranged
Admission Criteria
- Testicular torsion (emergent surgery)
- Fournier's gangrene
- Testicular abscess
- Severe orchitis with systemic illness
- Unable to exclude torsion
Referral
| Indication | Referral |
|---|---|
| Torsion | Urology emergent |
| Recurrent epididymitis | Urology |
| Testicular mass | Urology |
Patient Education
Condition Explanation
- "Your testicle twisted on itself, cutting off blood supply (torsion)." OR
- "You have an infection of the tube behind your testicle (epididymitis)."
Post-Operative (Torsion)
- Follow up with urology
- Watch for swelling, fever
- Activity restriction as directed
Epididymitis
- Complete full antibiotic course
- Sexual partners should be treated if STI
- Scrotal support and ice
- Follow up if not improving in 3 days
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Time to OR for torsion | under 6 hours | Salvage rate |
| Doppler ultrasound if uncertain | >0% | Diagnosis |
| Cremasteric reflex documented | 100% | Important finding |
| STI testing for epididymitis | >0% | Guideline adherence |
Documentation Requirements
- Onset and duration of pain
- Cremasteric reflex
- Testicular position
- Doppler findings
- Treatment and response
Key Clinical Pearls
Diagnostic Pearls
- High-riding, horizontal testicle = Torsion
- Absent cremasteric reflex = Torsion
- Sudden onset in adolescent = Torsion until proven otherwise
- Doppler: Absent flow = Torsion; Increased flow = Infection
- Blue dot sign = Appendix testis torsion
- Do NOT delay surgery for imaging if torsion highly suspected
Treatment Pearls
- Manual detorsion: "Open the book": Buys time
- Surgery still needed after manual detorsion: Orchiopexy
- Epididymitis in young male = STI: Ceftriaxone + Doxycycline
- Epididymitis in older male = Enteric: Fluoroquinolone
- Appendix torsion is self-limited: Conservative
Disposition Pearls
- Torsion = Emergent surgery
- Epididymitis can be discharged with antibiotics
- Fournier's = Emergent surgical debridement
- Follow-up all testicular complaints
References
- Sharp VJ, et al. Testicular torsion: Diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
- Ta A, et al. Testicular torsion and the acute scrotum. Curr Opin Pediatr. 2016;28(4):494-499.
- Boettcher M, et al. Clinical predictors of testicular torsion in boys. Eur J Pediatr. 2012;171(4):733-737.
- Wampler SM, et al. Common scrotal and testicular problems. Prim Care. 2010;37(3):613-626.
- Trojian TH, et al. Epididymitis and orchitis: An overview. Am Fam Physician. 2009;79(7):583-587.
- CDC. Sexually Transmitted Infections Treatment Guidelines. 2021.
- AUA Guidelines. Acute Scrotum. 2020.
- UpToDate. Evaluation of acute scrotal pain in adults. 2024.