Testicular Pain: What Could Be Causing It

Why Testicular Pain Has So Many Possible Causes

The scrotum receives sensory innervation from multiple nerve roots (ilioinguinal, genitofemoral, and pudendal nerves), which means pain can originate in the testicle itself, the epididymis, the spermatic cord, or from distant structures that share overlapping dermatomes. This neuroanatomy is the reason a kidney stone can produce scrotal pain indistinguishable from a local problem.

A 2018 retrospective review of 1,087 men presenting with acute scrotal pain at a U.S. emergency department found that epididymitis accounted for 45% of cases, testicular torsion for 16%, and no identifiable pathology for 13% [1]. Trauma, hernias, and hydroceles made up the remainder. The study underscored that age is one of the strongest discriminators: torsion peaks between ages 12 and 18, while epididymitis predominates after age 18 [2]. Clinicians at the American Urological Association (AUA) note that "the acute scrotum should be treated as torsion until proven otherwise, because delay beyond 6 hours significantly reduces testicular salvage rates" [3]. That single-sentence guideline drives the entire initial workup.

Testicular Torsion: The Surgical Emergency

Torsion occurs when the spermatic cord twists, cutting off arterial blood flow to the testis. Salvage rates drop sharply with time. A meta-analysis of 30 studies (N=2,116) reported a 90% salvage rate when detorsion occurred within 6 hours, falling to 54% between 6 and 12 hours and below 10% after 24 hours [4].

The classic presentation is sudden, severe unilateral pain, often waking the patient from sleep, accompanied by nausea or vomiting. On exam, the affected testis may sit higher than the contralateral side (high-riding testis), and the cremasteric reflex is typically absent. Color Doppler ultrasound confirms reduced or absent blood flow with a sensitivity exceeding 95% and specificity of 98% [5]. If clinical suspicion is high, many centers proceed directly to surgical exploration without waiting for imaging. The operation involves detorsion and bilateral orchiopexy (fixation of both testes to the scrotal wall) to prevent recurrence.

Neonatal torsion is a separate entity. It usually presents as a painless, firm, discolored hemiscrotum at birth and carries a poor prognosis for testicular viability because the twist often occurs prenatally.

Epididymitis and Epididymo-Orchitis

Epididymitis is inflammation of the epididymis, the coiled duct behind each testis. When infection spreads to the testis itself, the condition is called epididymo-orchitis. The CDC's 2021 STI Treatment Guidelines divide acute epididymitis by age and sexual history [6]:

• Sexually active men under 35: Chlamydia trachomatis and Neisseria gonorrhoeae are the most frequent pathogens. First-line treatment is a single intramuscular dose of ceftriaxone 500 mg plus doxycycline 100 mg orally twice daily for 10 days.
• Men over 35 or those practicing insertive anal intercourse: Enteric gram-negative organisms (especially E. coli) become more likely. Levofloxacin 500 mg daily for 10 days is recommended.

Pain onset in epididymitis is typically more gradual than in torsion, developing over hours to days rather than minutes. Scrotal elevation often relieves pain (positive Prehn sign), although this finding alone does not reliably exclude torsion. Urinalysis, urine culture, and nucleic acid amplification testing (NAAT) for chlamydia and gonorrhea guide antibiotic selection [6]. A Cochrane systematic review of antibiotic treatment for epididymitis noted clinical cure rates above 85% with guideline-concordant regimens, though post-treatment pain may linger for weeks in some patients [7].

Varicocele: The Most Common Structural Finding

A varicocele is an abnormal dilation of the pampiniform venous plexus within the spermatic cord. It affects approximately 15% of adult males in population-based studies and is found in up to 40% of men evaluated for infertility [8]. About 80-90% occur on the left side, owing to the left testicular vein's perpendicular drainage into the left renal vein.

Most varicoceles are asymptomatic. When pain occurs, it is typically described as a dull, aching heaviness that worsens with prolonged standing or exertion and improves with lying down. Physical exam reveals a "bag of worms" texture above the testis, more prominent with Valsalva. Scrotal ultrasound with color Doppler confirms the diagnosis when veins exceed 3 mm in diameter with retrograde flow during Valsalva [9].

Treatment is indicated for pain refractory to conservative measures (scrotal support, NSAIDs, activity modification) or for documented infertility. Surgical options include microsurgical subinguinal varicocelectomy and laparoscopic repair. Percutaneous embolization is a minimally invasive alternative. A randomized trial of 150 men found that microsurgical varicocelectomy produced significant semen parameter improvement in 66% of patients versus 35% in the observation group at 12 months [10]. Pain resolution rates after surgical repair range from 75% to 90% in published case series [11].

Referred Pain and Non-Scrotal Origins

Not all testicular pain starts in the scrotum. The testis shares afferent innervation with structures supplied by T10 through L1 nerve roots, creating the potential for referred pain from several sources:

• Ureteral calculi: A stone at the ureterovesical junction can produce ipsilateral scrotal pain. CT without contrast is the imaging standard [12].
• Inguinal hernia: An incarcerated or symptomatic inguinal hernia may present as scrotal discomfort, particularly when bowel or omentum extends into the scrotum.
• Lumbar disc disease: L1 radiculopathy can refer pain along the ilioinguinal nerve to the groin and scrotum. MRI of the lumbar spine is diagnostic.
• Retroperitoneal pathology: Rarely, retroperitoneal masses or aortic aneurysms produce testicular pain via direct nerve compression.

Dr. Larry Lipshultz, former president of the American Society for Reproductive Medicine, has stated: "Any man with chronic scrotal pain and a normal scrotal ultrasound should have his back and abdomen evaluated, because the pain often originates above the inguinal ligament" [13]. Missing a referred source leads to months of frustration and unnecessary scrotal procedures.

Chronic Orchialgia: When Pain Persists Beyond 3 Months

Chronic orchialgia (also called chronic scrotal content pain) is defined as intermittent or constant testicular pain lasting 3 months or longer that significantly interferes with daily activities [14]. The AUA estimates that chronic orchialgia accounts for up to 2.5% of all urology office visits [3].

The workup begins with ruling out treatable causes: infection, varicocele, spermatocele, hydrocele, inguinal hernia, and referred sources. When no structural or infectious etiology is found, the condition is classified as idiopathic chronic orchialgia. Spermatic cord block with local anesthetic serves as both a diagnostic and therapeutic tool. If a cord block at the external inguinal ring provides temporary relief, microsurgical denervation of the spermatic cord (MDSC) becomes a consideration.

A prospective study of 79 men who underwent MDSC after positive cord block showed complete pain resolution in 71% and partial improvement in an additional 17% at a median follow-up of 20 months [15]. Conservative management remains first-line: NSAIDs, pelvic floor physical therapy, tricyclic antidepressants (amitriptyline 10-25 mg nightly), and gabapentin (300-900 mg daily in divided doses). Cognitive behavioral therapy has shown benefit in small trials for patients with pain catastrophizing behaviors.

Testicular Cancer: Rare but Worth Excluding

Pain is present in roughly 10% of testicular cancer cases at diagnosis, though the classic presentation is a painless, firm mass [16]. Testicular cancer has a peak incidence between ages 15 and 35, with an annual incidence of approximately 5.7 per 100,000 men in the United States [17]. Risk factors include cryptorchidism (undescended testis), personal or family history of testicular cancer, and Klinefelter syndrome.

Scrotal ultrasound is the first imaging study. Solid intratesticular masses require urgent urology referral. Serum tumor markers (alpha-fetoprotein, beta-hCG, and lactate dehydrogenase) aid in staging and treatment planning. The five-year survival rate for localized testicular cancer exceeds 95%, making early detection and treatment highly effective [17]. Radical inguinal orchiectomy, not transscrotal biopsy, is the standard approach for suspicious masses.

How Testicular Pain Is Diagnosed: Step by Step

The diagnostic approach follows a structured sequence designed to identify or exclude surgical emergencies before pursuing less urgent causes:

1. History: Onset speed (seconds to minutes suggests torsion; hours to days suggests infection), laterality, associated symptoms (dysuria, urethral discharge, nausea), trauma history, and sexual history.
2. Physical exam: Testicular lie, cremasteric reflex, tenderness localized to the epididymis vs. the testis, presence of masses, inguinal hernia evaluation.
3. Urinalysis and urine culture: Pyuria suggests infection. NAAT for C. trachomatis and N. gonorrhoeae in at-risk populations [6].
4. Color Doppler ultrasound: First-line imaging with >95% sensitivity for torsion and excellent characterization of masses, cysts, hydroceles, and varicoceles [5].
5. Advanced imaging: CT abdomen/pelvis for suspected ureteral stones or retroperitoneal pathology. MRI lumbar spine if referred pain from disc disease is suspected.
6. Spermatic cord block: Diagnostic test for chronic orchialgia when standard workup is unrevealing [14].

No blood test is specific for acute scrotal pain. C-reactive protein and white blood cell count may be elevated in infection but do not differentiate between causes reliably.

Treatment Options by Diagnosis

Management depends entirely on the underlying cause.

Torsion: Immediate surgical exploration, manual detorsion as a temporizing measure, and bilateral orchiopexy. If the testis is nonviable, orchiectomy is performed with contralateral orchiopexy [4].

Epididymitis: Guideline-directed antibiotics based on age and risk factors (ceftriaxone plus doxycycline, or levofloxacin), NSAIDs for pain, scrotal elevation, and ice. Follow-up in 48-72 hours to confirm clinical improvement [6].

Varicocele: Conservative measures first (scrotal support, analgesics). Microsurgical varicocelectomy or percutaneous embolization for refractory pain or infertility [10].

Chronic orchialgia: Stepwise approach starting with NSAIDs and pelvic floor therapy, escalating to neuromodulators (amitriptyline, gabapentin), spermatic cord block, and MDSC if conservative therapy fails over 3-6 months [15].

Referred pain: Treat the primary source. Ureteral stones may require ureteroscopy or shockwave lithotripsy. Inguinal hernias require surgical repair. Radiculopathy is managed with physical therapy and, in refractory cases, epidural steroid injections.

Patients should seek emergency evaluation for sudden-onset severe pain, testicular swelling with fever, or a palpable firm mass. The 6-hour window for torsion makes this one of the few true urologic emergencies.