Testicular Pain (Pain in the Testicles)

  • Medical Author:
    Steven Doerr, MD

    Steven Doerr, MD, is a U.S. board-certified Emergency Medicine Physician. Dr. Doerr received his undergraduate degree in Spanish from the University of Colorado at Boulder. He graduated with his Medical Degree from the University Of Colorado Health Sciences Center in Denver, Colorado in 1998 and completed his residency training in Emergency Medicine from Denver Health Medical Center in Denver, Colorado in 2002, where he also served as Chief Resident.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Testicular pain definition and facts

  • Testicular pain refers to pain or discomfort that is felt in one or both testicles. The pain may be acute or chronic, dull, sharp, or a sensation of soreness or vague discomfort/ache.
  • The primary role of the testicle is to produce sperm and the hormone testosterone.
  • There are numerous conditions that can cause testicular pain, and a few of them constitute medical emergencies. The common causes of testicular pain include testicular torsion, epididymitis (caused by sexually transmitted diseases (STDs), torsion of the testicular appendage, kidney stones, testicular tumor, testicular trauma, inguinal hernia, and orchitis.
  • The signs and symptoms may include
    • pain,
    • swelling,
    • redness, and
    • tenderness of the testicle and/or scrotum.
  • Nausea, vomiting and fever may also be present.
  • The different causes of testicular pain can be diagnosed using blood tests, urinalysis and imaging studies, in addition to a complete physical exam.
  • The treatment for testicular pain varies depending on the underlying cause, and/or may include pain medication, antibiotics, and surgical intervention.
  • The complications of the conditions causing testicular pain may include infection, impaired fertility and permanent damage to the testicle, or loss of the testicle.
  • Only a few causes of testicular pain are preventable.

What are the testicles?

The testicles form part of the male reproductive organs, with a primary function of producing sperm and the male hormone testosterone.

The testicles are contained within an external sac-like structure called the scrotum, which is located between the penis and the anus. Adult testicles are similar in size to large olives, and it is common for one testicle to hang lower than the other within the scrotum. Located near the back of each testicle lies the epididymis, a coiled tubular structure which functions to store and transport sperm. The spermatic cord (a tubular structure containing blood vessels, nerves, lymphatic vessels and the vas deferens) courses from the abdomen and is connected to each testicle. Apart from containing vital structures for each testicle, the spermatic cord also suspends the testicles within the scrotum.

Picture of the male urinary and reproductive structures
Picture of the male urinary and reproductive structures

What is testicular pain (pain in the testicles)?

Testicular pain is pain or discomfort that is felt in one or both testicles. The pain may originate from the testicle itself, or it may be the result of other conditions affecting the scrotum, groin or abdomen. Though there are numerous medical conditions that can cause testicular pain, it is important to understand that a few of them constitute medical emergencies that require immediate medical attention in order to prevent impairment or loss of testicular function. Testicular pain can be an acute (short-term) or chronic (long-term) condition. The testicular pain may be constant or intermittent.

What are the signs and symptoms of conditions causing testicular pain?

Because there are numerous medical conditions that can lead to testicular pain in one or both testicles, the symptoms and signs may vary depending on the underlying cause. However, often times the symptoms can be very similar between the various causes, making it difficult to distinguish among the conditions which require urgent medical attention. Therefore, if you experience testicular pain, seek medical evaluation immediately by a trained professional.

Testicular torsion symptoms

Testicular torsion generally presents as sudden onset, severe testicle pain (localized to one testicle, left or right) that may be accompanied by any of the following signs and symptoms:

  • Nausea and vomiting
  • Testicular and/or scrotal tenderness
  • Testicular and/or scrotal swelling and redness
  • Abdominal pain
  • Fever
  • Elevation of the affected testicle within the scrotum
  • Horizontal positioning of the affected testicle within the scrotum
  • Loss of the cremasteric reflex on the affected side (normally, the testicle elevates with light stroking of the upper inner thigh area).

Epididymitis symptoms

Epididymitis generally presents as gradual onset, mild to severe testicle pain (localized to one testicle, right or left) that may be accompanied by any of the following signs and symptoms:

  • Nausea and vomiting
  • Testicular and/or scrotal tenderness, typically localized to the area of the epididymis, though it can become more generalized and involve the whole testicle as the illness progresses.
  • Testicular and/or scrotal swelling and redness
  • Abdominal pain
  • Fever
  • Urethral discharge
  • Urinary symptoms, such as burning, urgency, or frequency

Torsion of a testicular appendage symptoms

With torsion of a testicular appendage, the onset of testicle pain may be sudden or gradual, and the severity of pain may range from mild to severe. Generally, patients do not experience systemic symptoms, such as nausea, vomiting, and fever.

The testicle and/or scrotum generally appear normal, without swelling and redness; however, the following symptoms may be present.

  • Testicular tenderness, typically only localized to the top of the right or left testicle.
  • In some cases, a small blue-dot is visualized near the top of the affected testicle (blue-dot sign).

Preservation of the normal vertical positioning of the affected testicle within the scrotum, and preservation of the cremasteric reflex is generally maintained.

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Testicular (Ball) and Scrotum Pain Symptoms

Testicular pain can have a number of different causes, some of which constitute a medical emergency. Testicle or scrotum pain may be caused by

  • Trauma
  • Testicular torsion (a medical emergency)
  • Inflammation of the testicle or epididymis
  • Kidney stones
  • Tumors

Kidney stones symptoms

Occasionally, kidney stones can cause pain in the testicles. The testicles, however, appear normal without swelling or redness. Other signs and symptoms of kidney stones may include:

Testicular tumor symptoms

Although testicular tumors can occasionally cause testicular pain, they are usually painless. Signs and symptoms may include a:

  • Lump or mass of the testicle
  • Change in the size or texture of the testicle
  • Dull ache of the lower abdomen, lower back or groin area
  • Feeling of heaviness in the scrotum

Trauma and injury symptoms

In general, patients will relate a history of trauma to the genital area and testicular pain may range from severe to absent at the time the male goes to a health-care professional. Though in some cases the mechanism of injury may seem minor, serious underlying testicular injury may be present, and the following signs and symptoms may be observed:

  • Testicular and/or scrotal tenderness, swelling or bruising
  • Bruising of the area between the scrotum and the anus (perineum)
  • Nausea and vomiting.

Testicle rupture symptoms

This serious injury to the testicle results from a disruption to the connective tissue enveloping the testicle (tunica albuginea), leading to the extrusion of testicular tissue. This injury is often accompanied by a blood collection (hematocele) that surrounds the testicle.

Other types of injuries to the testicles include penetrating trauma and testicular dislocation. These types of testicular injuries typically require surgical management.

Inguinal hernia symptoms

Inguinal hernias are common and they can sometimes cause discomfort in the scrotum and/or testicles. Signs and symptoms of an inguinal hernia may include a:

  • Bulge in the scrotum or in the inguinal area, that may become more pronounced with coughing or straining; and
  • Dull ache or burning sensation in the scrotum and/or testicles.

Orchitis symptoms

Because orchitis generally occurs as a consequence of an infection (most often mumps), it is typically also accompanied by other systemic infectious symptoms. Testicular pain may range from mild to severe. Signs and symptoms of orchitis may include the following:

  • Testicular and/or scrotal tenderness, swelling or redness
  • Fever and chills
  • Headache
  • Body aches
  • Nausea
  • Fatigue
  • Parotid gland inflammation (parotitis) in cases of mumps

What are the complications of the conditions causing testicular pain?

The complications associated with the different causes of testicular pain are varied. Some individuals may suffer from chronic testicular pain, even after the acute cause of the testicular pain has been treated. Other potential complications may include the following.

Testicular torsion complications

  • Permanent damage to the testicle
  • Loss of testicle
  • Infertility
  • Infection
  • Cosmetic deformity

Epididymitis complications

  • Epididymo-orchitis
  • Abscess (a collection of pus) formation
  • Impaired fertility
  • Systemic blood infection (sepsis)

Torsion of a testicular appendage complications

  • No significant complications exist

Trauma complications

  • Permanent damage to the testicle
  • Atrophy (decrease in size) of the testicle
  • Loss of testicle
  • Infertility
  • Abscess formation
  • Cosmetic deformity
  • Testicular torsion

Inguinal hernia complications

  • Incarceration (hernia unable to be pushed back in)
  • Strangulation (disruption to the blood supply of the intestine protruding through the abdominal wall defect)

Orchitis complications

  • Atrophy of the testicle
  • Impaired fertility
  • Abscess formation

Kidney stone complications

  • Permanent kidney damage
  • Urosepsis (systemic blood infection arising from infected urine)

Testicular tumor complications

  • The complications of a testicular tumor vary depending on the underlying type of tumor and the extent of disease.

What causes testicular pain?

There are several medical conditions that can lead to testicular pain, and the pain can be acute or chronic in nature. As already described, some of these conditions require urgent evaluation and management in order to preserve testicular function.

Testicular torsion

  • This condition occurs when the testicle twists spontaneously within the scrotum, leading to a decrease in blood flow to the affected testicle (from the twisting of the vessels within the spermatic cord). If the blood supply is cut off for too long, the testicle will be permanently damaged. This condition is a medical emergency and requires immediate medical attention.
  • Testicular torsion typically occurs because of an anomaly affecting the normal attachment of the testicle within the scrotum, often referred to as the "bell clapper" deformity. This abnormality allows the testicle to be freely suspended and twist spontaneously. Often times, this anomaly is present in both testicles. Trauma to the testicle is a rare cause of testicular torsion.
  • Testicular torsion is most common in males younger than 30 years of age, with a peak incidence between 12-18 years of age. It can also occur more frequently during the neonatal period. Testicular torsion most often affects the left testicle, and it is the most common cause of testicle loss in adolescent males.

Epididymitis

  • This condition occurs when there is inflammation of the epididymis, generally as a result of an infection. Epididymitis primarily affects adults, and is most common between 19 to 40 years of age, though it can occur in the prepubertal and elderly age groups.
  • In sexually active men, the most common cause of infection is from a sexually transmitted disease (STD), most notably the bacterial organisms Chlamydia trachomatis and Neisseria gonorrhoeae. In younger and older individuals, infection is usually caused by bacteria that are found in the urinary tract, such as Escherichia coli. Infection in these age groups is typically the result of an abnormality within the genitourinary system.

Torsion of a testicular appendage causes

  • This condition occurs with torsion (twisting) of the testicular appendage or the epididymal appendage, functionless structures that are remnants of tissue from human development. The testicular appendage lies between the testicle and the epididymis, while the epididymal appendage typically projects from the epididymis. As with testicular torsion, twisting of these structures leads to a decrease in blood flow and subsequent testicular pain. This is a common condition in younger boys, with most cases occurring between 7 to 14 years of age. Though this condition is benign and self-limiting, it must be distinguished from the more serious testicular torsion.

Kidney stones

  • Occasionally, the pain associated with kidney stones can radiate into the groin area and cause testicular pain.

Testicular tumor

  • Though generally painless, tumors of the testicle can sometimes cause pain and discomfort of the testicle or scrotum.

Trauma and injuries

  • Any type of trauma or injury to the testicles can cause severe pain and discomfort. The most common mechanism of testicular trauma occurs from blunt trauma (~85%), which can occur from sports injuries, a direct kick to the area, car accidents, and straddle injuries. In most instances, the pain will improve with the passage of time. However, in a few instances, trauma to the testicles can cause more severe injuries requiring immediate medical attention.

Testicular rupture

  • Testicle rupture: This serious injury to the testicle results from a disruption to the connective tissue enveloping the testicle (tunica albuginea), leading to the extrusion of testicular tissue. This injury is often accompanied by a blood collection (hematocele) that surrounds the testicle.
  • Other types of injuries to the testicles include penetrating trauma and testicular dislocation. These types of testicular injuries typically require surgical management.

Inguinal hernia causes

  • An inguinal hernia is a bulge or protrusion of intestine through a defect in the abdominal wall musculature of the groin area. This protrusion can sometimes cause swelling of the scrotum and subsequent testicular pain.

Orchitis

  • This condition is characterized by inflammation of the testicle, typically as a result of an infection. Most cases of orchitis arise from a viral infection, with mumps being the most common causative illness. Mumps orchitis most commonly occurs in prepubertal males, though there has been an increase in cases in adolescent and postpubertal males secondary to the decreased use of the mumps vaccine. Less commonly, orchitis can occur from a bacterial infection, most often as the result of progression of epididymitis (epididymo-orchitis).

How are the causes of testicular pain diagnosed?

In order to diagnose the underlying condition causing testicular pain, a complete history and physical exam will be performed by a health-care professional. Laboratory testing and imaging studies may also be ordered depending on the health-care professional's initial impression and evaluation.

Laboratory testing may include:

  • Blood work
  • Urinalysis
  • A swab of the urethra (if the patient has penile discharge suggestive of a sexually transmitted disease)

Imaging studies may be ordered by your health-care professional to further delineate the underlying cause of the testicular pain. In certain patients with testicular pain whose symptoms are strongly suggestive of testicular torsion, immediate urologic consultation prior to testing should be obtained in order to prevent potential delays in definitive surgical management.

Imaging tests

Ultrasonography

A color Doppler testicular ultrasound is a non-invasive imaging study that can evaluate the blood flow to the testicles, as well as the presence of testicular tumors, fluid collections, testicular rupture, and hernias. A kidney ultrasound can be helpful in the evaluation of kidney stones.

Radionuclide imaging

This is an imaging study requiring the intravenous administration of a radionuclide, useful for the evaluation of testicular torsion, as well as other causes of testicular pain. It is used must less commonly than ultrasound.

CT scan or a kidney/ureter/bladder (KUB) X-ray

These particular imaging studies are sometimes ordered if there is a suspicion that the testicular pain is being caused by kidney stones or other conditions in the abdomen or pelvis.

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What is the treatment for testicular pain?

The treatment for testicular pain varies depending on the underlying cause. As already noted, some conditions causing testicular pain are medical emergencies requiring immediate surgical intervention.

Testicular torsion treatment

  • Definitive management of testicular torsion requires surgery by a urologist. During surgery, the affected testicle is untwisted, and if it is found to be viable, the testicle is secured to the scrotal wall (orchiopexy). The unaffected testicle may also be secured to prevent testicular torsion from occurring, as some males will have the bell clapper abnormality on both sides.
  • Sometimes, the affected testicle can be manually untwisted by a physician without necessitating emergent surgery, though this is a temporizing measure that ultimately still requires definitive surgical repair. Likewise, some cases of testicular torsion can occur and then resolve spontaneously, and the health-care professional must maintain a high index of suspicion in order for this condition to be diagnosed and ultimately surgically repaired.
  • The more rapidly the testicle is untwisted and blood flow is restored, the better the chances for salvaging the affected testicle. If treated within 6 hours of symptom onset, the salvage rate nears 100%, while after 24 hours the salvage rate is between 0% and 10%.

Epididymitis treatment

The treatment of uncomplicated epididymitis can generally be managed as an outpatient, and consists of the following treatment measures:

  • Antibiotics (which may vary depending on the patient's age and sexual history), pain medication and anti-inflammatory agents
  • Rest
  • Scrotal support and elevation
  • Ice packs

In general, acute epididymitis that is properly treated resolves without complications. However, in some cases of epididymitis, such as those associated with serious systemic symptoms or in those accompanied by various complications, hospitalization may be necessary. A urologist will be consulted in these more serious cases.

Torsion of a testicular appendage treatment

The treatment for torsion of the testicular or epididymal appendage is directed toward relief of symptoms, and consists of the following measures:

  • Pain medication and anti-inflammatory agents
  • Rest
  • Scrotal support and elevation
  • Ice packs

Most patients improve with these treatment measures within 1 week, though symptoms may last longer. In cases of testicular pain refractory to conservative management, surgical excision of the affected tissue is considered.

Kidney stone treatment

The treatment for kidney stones generally depends on the location of the kidney stone, the size of the kidney stone, and any associated complications, such as infection. An uncomplicated kidney stone can typically be treated with the following measures:

  • Adequate fluid intake
  • Pain medication
  • Anti- nausea medication
  • In some instances medications such as tamsulosin (Flomax), which may facilitate the passage of kidney stones

Several different measures exist for treating kidney stones that do not pass spontaneously, such as lithotripsy (the use of shock waves to break up the kidney stone) and other more invasive surgical procedures.

Certain patients with intractable pain, intractable vomiting or those with signs of infection require hospitalization. In those with urinary tract infection and an obstruction in the genitourinary system, antibiotics and emergent urologic intervention is necessary.

Testicular tumor treatment

  • The treatment for a testicular tumor depends on various factors. A testicular mass is considered cancer until proven otherwise. If testicular cancer is diagnosed, patients are referred to an oncologist who will discuss the different treatment options available.

Trauma treatment

The treatment and management of testicular trauma depends on the severity of injury. Minor cases of testicular trauma without suspected serious underlying testicular injury can be managed as an outpatient with the following measures:

  • Pain medication and anti-inflammatory agents
  • Rest
  • Scrotal support and elevation
  • Ice packs

With testicular rupture, immediate surgical repair is necessary to preserve testicular function and viability. Other situations requiring surgical management include certain blunt trauma injuries with associated blood collections (hematoceles), penetrating trauma, and certain cases of testicular dislocation.

Inguinal hernia treatment

  • The definitive treatment of inguinal hernias requires surgical repair, sometimes electively as an outpatient, while others require intervention on a more emergent basis. Occasionally, inguinal hernias may not be repaired even electively because a patient is too high-risk to undergo surgery.
  • Prompt surgical intervention is necessary in cases of inguinal hernias that are not reducible (unable to be pushed back into the abdomen) and in those cases of strangulation (disruption to the blood supply of the intestine).

Orchitis treatment

The treatment of orchitis depends on the infectious organism responsible for causing the testicular inflammation. Both viral and bacterial orchitis can be treated with the following measures:

  • Pain medication and anti-inflammatory agents
  • Rest
  • Scrotal support and elevation
  • Ice packs

Bacterial orchitis and epididymo-orchitis require antibiotics. Those cases caused by viruses do not require antibiotics.

How can testicular pain be prevented?

There are a few measures that you can take to prevent certain causes of testicular pain. However, many of the causes are not entirely preventable.

  • For epididymitis or bacterial orchitis caused by sexually transmitted diseases (STDs), condom use can reduce the risk of transmission of STDs.
  • The use of appropriate protective gear during sporting activities can help prevent testicular trauma.
  • Mumps immunization can decrease the incidence of viral orchitis.

REFERENCES:

American Urological Association. "Acute Scrotum." Updated: July 2016.
<https://www.auanet.org/education/acute-scrotum.cfm>

Urology Care Foundation.
<http://www.urologyhealth.org>

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Reviewed on 12/14/2016
References
REFERENCES:

American Urological Association. "Acute Scrotum." Updated: July 2016.
<https://www.auanet.org/education/acute-scrotum.cfm>

Urology Care Foundation.
<http://www.urologyhealth.org>

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