One-liner#

Acute scrotal pain is testicular torsion until proven otherwise—time-sensitive diagnosis requiring urgent evaluation if torsion cannot be confidently excluded.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Acute severe scrotal pain <6 hours duration → assume torsion until proven otherwise; ED for emergent ultrasound
• High-riding or horizontal testis → torsion; ED immediately
• Absent cremasteric reflex → highly suggestive of torsion
• Nausea/vomiting with scrotal pain → common with torsion
• Scrotal erythema, swelling, crepitus, systemic toxicity → Fournier’s gangrene; surgical emergency
• Trauma with significant swelling or hematoma → possible testicular rupture; needs imaging

Key history#

Characterize the pain:

• Onset: sudden (torsion, trauma) vs gradual (epididymitis, hernia)
• Duration: <6 hours is critical window for torsion
• Location: testicular vs epididymal vs referred
• Severity: torsion is typically severe (10/10)
• Radiation: to groin, lower abdomen

Critical questions for torsion:

• Exact time of onset (salvage rate drops significantly after 6 hours)
• Prior episodes of similar pain that resolved (intermittent torsion)
• History of undescended testis (increased torsion risk)
• Recent trauma

Associated symptoms:

• Dysuria, urethral discharge → epididymitis (STI or enteric)
• Fever → infection (epididymitis, orchitis, abscess)
• Nausea/vomiting → common with torsion
• Inguinal bulge → hernia
• Recent viral illness → viral orchitis (mumps)

Sexual history (for epididymitis):

• Age <35 with STI risk factors → likely chlamydia/gonorrhea
• Age >35 or recent instrumentation → likely enteric organisms

Other history:

• Recent heavy lifting (hernia)
• Vasectomy (post-vasectomy pain syndrome)
• Prior scrotal surgery
• Anticoagulation (scrotal hematoma)

Focused exam#

General:

• Vital signs: fever suggests infection
• Patient appearance: writhing (torsion) vs lying still

Scrotal exam (compare sides):

• Inspection: erythema, swelling, asymmetry, skin changes
• Palpation: localize tenderness (testis vs epididymis vs cord)
• Testicular lie: horizontal or high-riding (torsion)
• Cremasteric reflex: stroke inner thigh, observe testicular elevation (absent in torsion)
• Prehn sign: elevation of scrotum relieves pain (classically positive in epididymitis, negative in torsion)—unreliable but still assessed

Key exam findings by diagnosis:

• Torsion: high-riding testis, horizontal lie, absent cremasteric reflex, diffuse testicular tenderness
• Epididymitis: tender, swollen epididymis (posterior); testis itself less tender initially
• Torsion of appendix testis: point tenderness at upper pole; “blue dot sign” (visible through skin)
• Hernia: inguinal bulge; may reduce with positioning
• Hydrocele: transilluminates; non-tender

Inguinal exam:

• Inguinal hernia
• Lymphadenopathy

Abdominal exam:

• Referred pain from renal colic, appendicitis

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Suspected torsion:

• Do NOT delay for workup—if high suspicion, send to ED immediately
• Scrotal ultrasound with Doppler: absent or decreased blood flow confirms torsion
• If ultrasound unavailable or delayed, surgical exploration is appropriate

Suspected epididymitis:

• UA: pyuria supports diagnosis
• Urine culture: if enteric organisms suspected
• NAAT for chlamydia/gonorrhea: if age <35 or STI risk factors
• Consider HIV, syphilis testing if new STI diagnosis

Scrotal mass/swelling:

• Scrotal ultrasound: differentiates hydrocele, varicocele, tumor, epididymal cyst
• Tumor markers (AFP, beta-hCG, LDH): if testicular mass concerning for cancer

When to image:

• Acute scrotal pain with any concern for torsion → emergent ultrasound (ED)
• Scrotal mass → ultrasound
• Trauma with significant swelling → ultrasound
• Epididymitis not responding to treatment → ultrasound to rule out abscess

When NOT to order:

• Do NOT delay ED referral for ultrasound if torsion is suspected—time is testicle
• Do NOT order ultrasound for obvious hydrocele or varicocele unless diagnostic uncertainty
• Do NOT reassure based on “positive Prehn sign”—this is unreliable

Initial management#

Suspected torsion:

• ED immediately
• Manual detorsion can be attempted while awaiting transfer: “open the book” (rotate testis outward/laterally)
• Do NOT delay transfer for manual detorsion attempts

Epididymitis:

• Antibiotics based on likely organism (see management section)
• Scrotal support (briefs, jockstrap)
• NSAIDs for pain
• Ice packs
• Activity restriction

Torsion of appendix testis:

• Supportive care
• NSAIDs
• Scrotal support
• Resolves spontaneously in 1-2 weeks

Incarcerated hernia:

• ED for surgical evaluation
• Attempt gentle reduction only if no signs of strangulation

Management by diagnosis#

Epididymitis#

Education:

• Infection of the tube behind the testicle
• Usually caused by bacteria; may be sexually transmitted in younger men
• Takes 1-2 weeks to fully resolve; swelling may persist longer
• Partners need treatment if STI-related

Treatment by likely organism:

Age <35 or STI risk factors (chlamydia/gonorrhea likely):

Age >35 or enteric organisms likely (recent UTI, instrumentation, insertive anal sex):

Supportive care:

• Scrotal elevation/support
• NSAIDs (ibuprofen 400-600 mg TID)
• Ice packs 20 minutes several times daily
• Activity restriction; avoid heavy lifting

Follow-up: 48-72 hours if not improving; 2 weeks for resolution. If not improving, ultrasound to rule out abscess.

Orchitis#

Education:

• Testicular inflammation, often viral (mumps) or extension from epididymitis
• Mumps orchitis: occurs 4-8 days after parotitis; can cause infertility if bilateral
• Bacterial orchitis usually accompanies epididymitis

Treatment:

• Viral (mumps): supportive care, NSAIDs, scrotal support
• Bacterial: treat as epididymitis

Follow-up: Urology referral if concern for abscess or not improving.

Torsion of Appendix Testis#

Education:

• Small tissue remnant at top of testicle has twisted
• Not dangerous; will resolve on its own in 1-2 weeks
• Pain may worsen before it improves

Treatment:

• NSAIDs: ibuprofen 400-600 mg TID
• Scrotal support
• Activity restriction as tolerated
• Ice packs for comfort

Follow-up: Return if pain worsening, fever, or not improving after 2 weeks.

Varicocele#

Education:

• Dilated veins around testicle (like varicose veins)
• Usually left-sided; harmless in most cases
• Can affect fertility in some men
• Surgery only if symptomatic or fertility concern

PCP role:

• Reassurance if asymptomatic
• Scrotal support for comfort
• Urology referral if: symptomatic, fertility concerns, new right-sided varicocele (evaluate for retroperitoneal mass)

Follow-up: As needed for symptoms.

Hydrocele#

Education:

• Fluid collection around testicle
• Usually painless and harmless
• Can be observed if not bothersome
• Surgery if large or uncomfortable

PCP role:

• Confirm diagnosis (transilluminates, non-tender)
• Reassurance if small and asymptomatic
• Urology referral if: large, symptomatic, or diagnostic uncertainty

Follow-up: As needed.

Testicular Cancer (Suspected)#

Recognition:

• Painless testicular mass (most common presentation)
• Firm, does not transilluminate
• Peak age 15-35
• Risk factors: cryptorchidism, family history, prior testicular cancer

PCP role:

• Recognize and refer urgently
• Order scrotal ultrasound
• Do NOT delay referral for tumor markers

Referral: Urgent urology (within 1-2 weeks).

Follow-up#

Epididymitis:

• Phone check 48-72 hours
• Office visit 2 weeks to confirm resolution
• If not improving: ultrasound, consider abscess, resistant organism, or alternative diagnosis

Torsion of appendix testis:

• Return if not improving in 2 weeks

After torsion (surgical):

• Urology manages post-operatively
• Contralateral orchiopexy usually performed to prevent future torsion

Return precautions (all patients):

• Worsening pain
• Fever (new or worsening)
• Swelling increasing
• Skin changes (redness spreading, darkening)
• Nausea/vomiting
• Unable to urinate

Patient instructions#

For epididymitis:

• Take all your antibiotics as prescribed
• Wear supportive underwear (briefs, not boxers) or a jockstrap
• Use ice packs wrapped in a towel for 20 minutes several times a day
• Take ibuprofen for pain and swelling
• Avoid heavy lifting and strenuous activity until pain resolves
• If this is from a sexually transmitted infection, your partner(s) need treatment too
• Call or return if: fever, pain getting worse, swelling increasing, or not improving after a few days

For torsion of appendix testis:

• This is a minor condition that will heal on its own in 1-2 weeks
• Take ibuprofen for pain
• Wear supportive underwear
• The pain may get a little worse before it gets better
• Call or return if: severe worsening pain, fever, or not improving after 2 weeks

Smartphrase snippets#

Epididymitis (STI-related): “Presentation consistent with acute epididymitis—gradual onset scrotal pain, tender epididymis, intact cremasteric reflex. Given age and risk factors, treating for STI etiology with ceftriaxone 500 mg IM + doxycycline 100 mg BID x 10 days. NAAT sent for CT/GC. Partner treatment discussed. Supportive care reviewed. Return if worsening or not improving in 48-72 hours.”

Epididymitis (enteric): “Acute epididymitis in [age >35/recent instrumentation/UTI history]. Treating with levofloxacin 500 mg daily x 10 days for likely enteric organisms. UA/culture sent. Supportive care with scrotal support, NSAIDs, ice. Follow-up in 2 weeks or sooner if not improving.”

Torsion ruled out: “Acute scrotal pain evaluated. Exam: [cremasteric reflex intact, testis normal lie, tenderness localized to epididymis/appendix]. Low suspicion for torsion given [gradual onset, intact reflex, localized tenderness]. Diagnosis: [epididymitis/torsion of appendix testis]. Treated with [regimen]. Strict return precautions given for worsening pain, which would warrant emergent ultrasound.”