Acute Scrotal Pain

One of the most challenging aspects of male genitourinary complaints is that a wide variety of clinical conditions may all be manifested as acute, unilateral (or bilateral) pain and swelling of the scrotum. Although the differential diagnosis for such symptoms is extensive, threats to life and fertility need to be excluded. Testicular torsion, Fournier gangrene, and an incarcerated or strangulated inguinal hernia are surgical emergencies. The vast majority of acute testicular pain, however, can be attributed to one of three diagnostic entities: testicular torsion, epididymitis, or appendage torsion (Table 111.1).¹

Table 111.1 Differentiation of Testicular Torsion, Epididymitis, and Appendage Torsion

History

Pain may be due to structures within or adjoining a particular region or may be referred from other areas. Delineation of the source of the pathology is essential. For example, pain from abdominal aortic aneurysms, renal colic, and pyelonephritis can radiate to the testicles.

Onset of Symptoms

Pain that begins abruptly and is severe suggests testicular torsion.² Intermittent severe pain can signal intermittent torsion. Twisting of the spermatic cord leads to rapid diminution of blood supply to the affected testicle and resultant ischemic pain. This is in contrast to the more indolent pain of epididymitis, a gradually progressive inflammatory process. Patients with long-standing inguinal hernias often complain of isolated genital pain of prolonged duration. However, patients with an incarcerated (cannot be reduced) or strangulated hernia (with ischemic or infarcted, herniated bowel) may experience more acute pain.

Testicular torsion may accompany a report of minor scrotal trauma.³ Testicular torsion can also take place in the absence of such events and may even occur during sleep.

Character of Symptoms

The distinction between constant progressive and intermittent colicky pain is potentially useful in the diagnosis of acute scrotal pain. Constant and progressive pain typically results from progressive inflammatory processes such as epididymitis. Patients may exhibit pain with ambulation and other movements as a result of the inflammation. Intermittent and colicky pain is more consistent with rapid onset and offset conditions, as occurs with twisting of the spermatic cord, either suddenly or intermittently.

Patients with testicular torsion often complain of severe pain as a consequence of ongoing testicular ischemia. Pain resulting from inflammatory processes (epididymitis) may be relieved temporarily by rest and scrotal elevation with a supportive undergarment such as a jockstrap. Similarly, the inflammatory pain is often exacerbated by movement, thus leading a patient to remain still. Alternatively, patients exhibiting the colicky symptoms of testicular torsion may writhe in pain as they try (and often fail) to find a position of comfort. These symptoms are generalizations and, when considered alone, lack high sensitivity or specificity.

Associated Symptoms

Patients with nausea or emesis are less likely to have torsion of an appendage or simple, uncomplicated epididymitis. It is more likely that substantial pathology is present. Patients with abdominal pain, nausea, or constitutional symptoms may have testicular torsion, an incarcerated hernia, or another process.^2,4,5 Patients with epididymitis may have a low-grade fever, nausea, and malaise; those with advanced infection (e.g., epididymoorchitis) may demonstrate more pronounced constitutional symptoms.⁶

Urinary symptoms such as dysuria and urgency may accompany epididymitis. Inability to void spontaneously may indicate either urethral obstruction or severe volume depletion. A yellow-green penile discharge may provide clues to the diagnosis of urethritis or epididymitis, often caused by gonorrhea or Chlamydia infection in sexually active males.

Abdominal Examination

Because many intraabdominal conditions may be associated with genitourinary pain, abdominal, flank, and back evaluation is useful. It is important to assess for lower abdominal tenderness or a mass, which potentially signals acute appendicitis, inguinal hernia, genitourinary malignancy, abdominal trauma, or an advanced perineal infection such as Fournier gangrene. Tenderness at the costovertebral angle may be present with retroperitoneal processes such as pyelonephritis, renal colic, and an expanding or ruptured abdominal aortic aneurysm.

Genital Examination

The genitalia should be examined while the patient is both standing and lying supine. Caution should be used when examining a standing patient because some males experience a strong vagal response to scrotal (or prostate) stimulation that can lead to presyncope or syncope. In addition, examination of the testicles and epididymis may cause significant discomfort, even in the absence of pathology. Because many patients have unilateral pain, the unaffected side should be examined first. This serves as a control and helps gain the trust of the patient.

Visual examination of the genitals may reveal cutaneous rashes or lesions, abnormal testicular symmetry or position, edema evident by loss of the scrotal skin folds, and masses. Key visual features of testicular torsion include a high-riding and transverse lie of the affected testicle.^2,4,7

It is important to look for evidence of scrotal and perineal erythema or ecchymoses, particularly in older patients with scrotal pain. This may be the only clue to the presence of Fournier gangrene, which often affects diabetics and other immunocompromised individuals. However, a prominent feature of necrotizing fasciitis is significant pain in the absence of pronounced physical findings.

A digital rectal examination provides information regarding the prostate and the prostatic portion of the urethra. Exquisite prostate tenderness may indicate acute prostatitis. Firmness and enlargement of the prostate are typically signs of benign prostatic hypertrophy; nodularity is concerning for prostatic carcinoma. These conditions may be accompanied by variable genitourinary symptoms.

Acute Penile Pain

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