Testicular Pain

Differential Diagnosis

Occasional Diagnoses

Rare Diagnoses

  • Testicular Carcinoma (Teratoma and Seminoma)
  • Incarcerated or Strangulated Inguinoscrotal Hernia
  • Syphilis
  • Referred from Spinal Tumours
  • Neuralgia Testis
  • Tuberculosis of the Testis

Ready Reckoner

Key distinguishing features of the most common diagnoses

OrchitisEOTorsionEpididymal CystStone
Testicle TenderYesYesYesNoNo
Urethral DischargeNoPossibleNoNoNo
Testis High in ScrotumNoNoYesNoNo
Transilluminating LumpNoNoNoPossibleNo

Possible Investigations

Likely:Urinalysis, MSU.

Possible:Urethral swab, ultrasound.

Small Print:Lumbosacral spine and abdominal X-rays, syphilis serology.

  • Urinalysis: Protein, blood and pus cells in EO. Blood alone with stone.
  • MSU: Will identify UTI.
  • Urethral swab for gonococcus and Chlamydia necessary if STD suspected.
  • Plain lumbosacral spine and abdominal X-rays are valuable to investigate referred testicular pain (stones and spinal pathology).
  • Ultrasound is good at ‘seeing’ if a testicular mass arises from the body of the testis or its coverings, and whether solid or not.
  • Syphilis serology: If syphilis suspected.

Top Tips

  • In an adult, relief of pain by elevating the testicle suggests epididymitis.
  • A negative urinalysis does not exclude epididymitis.
  • In mild, chronic testicular ache, examine the patient standing up, otherwise you may miss a varicocoele.

Red Flags

  • A sudden onset of excruciating pain associated with nausea suggests torsion of testis – especially in children and adolescents. Admit immediately.
  • Repeated episodes of spontaneously resolving pain may represent recurrent, self-correcting torsion. Refer for possible orchidopexy and warn the patient to report urgently if there is severe and persisting pain.
  • If non-gonococcal/chlamydial epididymitis is clinically suspected, treat immediately with a broad-spectrum antibiotic.
  • If epididymitis does not settle with antibiotics, consider abscess formation – admit for IV antibiotics or surgical drainage.

Published: 2nd August 2022 Updated: 10th April 2024

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