Testicular Pain
This is an uncommon symptom in everyday general practice. Though commonest in the young adult, it can affect all age groups. In its acute form, it is excruciating and disabling. In the chronic form it is usually described as a dull ache or dragging sensation. It is the former which causes the GP the most diagnostic difficulty and anxiety.
Differential diagnosis
Common Diagnoses
- Acute Orchitis (Mumps, and Less Commonly Scarlet Fever and Flu)
- Acute Epididymo-Orchitis (EO) (UTI and Sexually Transmitted Infection)
- Torsion of the Testis
- Epididymal Cyst
- Referred from Ureteric Stone
Occasional Diagnoses
- Idiopathic Chronic Testicular Pain (Accounts For 25% of Chronic Cases)
- Varicocoele
- Haematocoele
- Hydrocoele
- Trauma (Fractured Testis)
- Undescended or Misplaced Testis
- Torsion of the Appendix Testis
- Post-Vasectomy Pain
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
| Orchitis | EO | Torsion | Epididymal Cyst | Stone | |
|---|---|---|---|---|---|
| Testicle Tender | Yes | Yes | Yes | No | No |
| Urethral Discharge | No | Possible | No | No | No |
| Fever | Yes | Possible | No | No | No |
| Testis High in Scrotum | No | No | Yes | No | No |
| Transilluminating Lump | No | No | No | Possible | No |
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.