creation date: 2026-01-20 00:40
tags: Workups
Acute Scrotal Pain
Background
Acute scrotum is moderate to severe scrotal pain developing over minutes to 1-2 days.
Conditions range from those requiring immediate surgical intervention to just supportive care and reassurance.
Relevant Anatomy
Testes: male gonad responsible for sperm and androgen production
- 3-5 cm in length
- Ovoid shape
- Firm with smooth surfaces
- Left testis typically hangs lower due to longer spermatic cord length
Tunica vaginalis: fascial layer that encompasses anterior two-thirds of the testis
- Encapsulates a potential space that fluid can accumulate in
Epididymis: coiled tubular structure located on the posterior aspect of testis running from the superior and inferior poles.
- Connects the tubules of the rete testes to the vas deferens
- Stores and transports sperm cells
Spermatic cord: consist of testicular blood vessels and vas deferens
- Connects epididymis and travels retropubic
- Left cord is longer; the left gonadal vein drains to left renal vein (longer path), right gonadal vein drains directly into IVC
Appendix testis: small vestigial structure on anterosuperior aspect of the testis, embryologic remnant of Mullerian duct system
Appendix epididymis: Wolffian duct vestigial structure at top of epididymus
Differential Diagnosis
Initial Evaluation
Goal of initial evaluation is to differentiate between acute epididymitis, necrotizing fasciitis, and testicular torsion. The latter two being surgical emergency and thus prompt identification.
Identify Urgent Conditions
Necrotizing fasciitis
- Systemic illness
- Hemodynamic instability
- Rapidly progressive erythema/edema of overlying soft tissues of scrotum
- RFs: DM, urethral trauma, immunocompromise, chronic indwelling catheter
Testicular torsion
- Unilateral pain
- Ischemia of testicle
- Identified with ultrasound within 8 hours
History
History should include nature, timing of onset, location of pain.
Additionally, presence of the following should be noted:
- Fever
- Lower urinary tract symptoms
- Sexual activity
Relevant PMHx include:
- BPH or obstructive uropathy
- Recent urologic instrumentation
Physical Exam
Inspect the abdomen, inguinal region, and scrotal skin and content.
- Erythema and edema
- Positioning of testes
Palpation should be thorough for a tender mass or knot.
- Positive Prehn sign: relief from manual elevation of testes
- Cremasteric reflex: patient supine, stroke medial portion of thigh downwards. Normal response causes contraction of ipsilateral testis superiorly
Additional examination of inguinal canal for hernia as it may cause referred scrotal pain. A tender prostate on DRE is suggestive of prostatitis which may present with epididymitis.
Investigations
Imaging consist of testicular ultrasound. This is indicated if not already done and diagnosis is uncertain.
Laboratory testing depends on clinical suspicion and includes:
- Urinalysis
- Screening for STI