⚠️ Scrotal pain and swelling require urgent assessment. - Testicular torsion 🚨 is a surgical emergency; salvage rates fall steeply beyond 6 hours. - Testicular tumours 🎗️ are classically painless, but need rapid referral for early cure.

📖 Introduction

Scrotal pain is a common yet diagnostically challenging presentation, spanning benign self-limiting causes to life-threatening emergencies.
Lumps/swelling may arise from the testis, epididymis, spermatic cord, or adjacent structures; they can also reflect referred pain from the abdomen or spine.
Early recognition, particularly of torsion and tumour, is crucial to preserve fertility, prevent necrosis, and avoid missed cancers.

🔬 Pathophysiology

Testicular torsion: Twisting of the spermatic cord → venous outflow obstruction → arterial compromise → ischaemia → infarction. Necrosis develops within hours.
Epididymo-orchitis: Bacterial or viral inflammation causes neutrophilic infiltration, swelling, fever, and tenderness. Pathogens vary with age (STIs in young men, coliforms in older).
Hydrocele / Cyst: Imbalance of fluid secretion and absorption in tunica vaginalis or epididymal ducts → fluctuant, transilluminating swelling.
Tumours: Malignant germ cell proliferation → firm, intratesticular mass, often painless.
Other causes: Trauma (haematoma/rupture), vascular (infarction, sickle cell), congenital remnants (torsion of hydatid), or referred pain (renal colic, hernia).

🩺 Clinical Assessment

History: Onset (sudden vs gradual), severity, urinary/STI history, trauma, systemic symptoms.
Examination: Inspect for swelling, erythema, testicular lie. Palpate for tenderness, lump consistency, transillumination, reducibility of hernia.
Cremasteric reflex: Most sensitive sign for torsion (absent in torsion, preserved in infection).
Always examine abdomen and groin - hernia and renal colic can mimic testicular pathology.

⚡ Causes of Scrotal Pain & Swelling


Differential	Key Clinical Features	Investigations	Management
Testicular Torsion ⏱️	Sudden severe pain, high-riding testis, absent cremasteric reflex, nausea/vomiting.	Urgent Doppler US if equivocal - but do not delay surgery.	Immediate surgical detorsion + bilateral orchiopexy; orchidectomy if non-viable.
Epididymo-orchitis 🦠	Gradual onset pain, tender swelling, fever, LUTS, urethral discharge.	Urinalysis, urine culture, STI NAAT, US (↑ flow).	Antibiotics (STI: ceftriaxone + doxycycline; coliform: quinolone/Co-amoxiclav), NSAIDs, scrotal support.
Hydrocele 💧	Painless swelling, transilluminates, fluctuant.	USS to exclude underlying tumour.	Reassure; surgery if large or symptomatic.
Torted Hydatid of Morgagni 🌱	Upper pole pain, “blue dot sign”.	USS to exclude torsion.	Supportive once torsion excluded.
Varicocele 🩸	Dull ache, “bag of worms”, worse on standing, may affect fertility.	USS with Doppler.	Ligation or embolisation if symptomatic/fertility concern.
Testicular Tumour 🎗️	Painless firm mass, heaviness, ± gynaecomastia.	USS (solid mass), AFP, β-hCG, LDH, CT for staging.	Radical inguinal orchidectomy ± chemo/radiotherapy. Never biopsy trans-scrotally.
Trauma 🥊	Acute pain, bruising, swelling; history of injury.	USS for rupture/haematoma.	Supportive (ice, NSAIDs) or surgical exploration if rupture suspected.
Other causes	Hernia (groin bulge), renal colic (loin-to-groin pain), vascular (sickle cell, vasculitis).	Clinical ± targeted imaging.	Treat underlying pathology.

🔍 Investigations

Scrotal ultrasound with Doppler: First-line in uncertain cases.
Urinalysis & culture: Infection assessment.
STI screen (NAAT): In young, sexually active men.
Tumour markers (AFP, β-hCG, LDH): If mass suspected.
CT / CXR: Staging in confirmed malignancy.
Rule: Do not delay urgent torsion exploration for imaging if suspicion is high.

💊 Management Principles

Surgical: torsion, hernia, cancer, large hydroceles, symptomatic varicoceles, trauma with rupture.
Medical: antibiotics for infection, analgesia (NSAIDs, paracetamol), STI-directed therapy.
Supportive: scrotal elevation, rest, hydration, reassurance for benign lesions.
Follow-up: oncological surveillance for tumours, fertility counselling if bilateral pathology.

🚨 Red Flags

Torsion: assume until proven otherwise in acute severe pain.
Testicular cancer: any painless lump = urgent urology referral (2-week wait, UK).
Strangulated hernia: irreducible tender swelling + systemic upset requires urgent surgery.

📚 Summary

👉 Scrotal pain has a broad differential but always exclude torsion first. 👉 Painless masses can be sinister - ultrasound and early referral are essential. 👉 Early recognition prevents testicular loss, infertility, or missed cancer diagnoses.

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Scrotal/testicular pain/lump/swelling ⚠️