Testicular and scrotal pain may be caused by several injuries or diseases. Pain in this sensitive area is cause for concern in any man or boy, as it may be an indicator of serious damage. However, most incidences of testicular and scrotal pain tend to be moderate.

Trauma or infection often causes testicular and scrotal pain directly. Common activities associated with direct testicular and scrotal pain include athletic injury and sexual activity. In some cases testicular pain is due to a condition requiring immediate medical attention, such as testicular torsion, an aortic aneurysm or appendicitis.

In most cases, a physician can diagnose the source of testicular and scrotal pain by taking a patient’s medical history and performing a physical examination. In more serious cases, certain tests such as ultrasound or urinalysis may also be performed to assess the pain source and its severity.

Moderate testicular and scrotal pain can often be relieved with common remedies such as rest, elevation, ice pack and nonsteroidal anti-inflammatory drugs. In more serious cases, additional measures may be necessary, such as surgery or antibiotics.

Total prevention of testicular and scrotal pain resulting from injury or disease is unrealistic, given the many ways it can happen. However, males can reduce their risk by wearing protective athletic gear and protecting against certain sexually transmitted diseases.

Testicular and scrotal pain is cause for concern for males of all ages. A wide range of conditions and injuries can cause pain in the testicles or the scrotum. Some may simply require explanation or reassurance to the patient, whereas others may require quick and extensive diagnosis and treatment. Nevertheless, a general understanding of the male reproductive system can be helpful in understanding sources of testicular and scrotal pain.  

Testicles (testes) first form in the womb inside the fetal abdominal cavity. At somewhere between 32 and 40 weeks of gestation, they descend from the abdomen into the scrotum, the external sac containing the testicles. When fully developed, the testicles are oval-shaped with one on the left side and one on the right side of the scrotum. The two central functions of the testicles are to produce sperm (male reproductive cell) and testosterone (male sex hormone).

The scrotum serves a number of functions, including regulating testicular temperature for the best possible sperm and testosterone production by being separate from the rest of the body. The temperature of the scrotal sac is about 2 degrees Fahrenheit below the body temperature. The cremasteric muscles (muscles in the scrotum) move the testicles within the scrotum according to the surrounding temperature. After sperm is produced in the testicles, it exits through a coiled, tube-like structure (epididymis) before traveling through a connector tube (vas deferens) and eventually out of the body. 

Injury or infection to these and other anatomical structures (e.g., prostate gland, urethra [tube that discharges urine and semen from the body]) can lead to testicular and scrotal pain in certain cases. Testicular and scrotal pain can range from moderate and short-lived (e.g., minor trauma) to severe with long-term aftereffects.   

There are several specific symptoms associated with testicular and scrotal pain. Many of these occur as a result of trauma, infection or physical activity. These related symptoms include:

• Swelling in the testicles or scrotum
• Tenderness in one or both testicles
• Abdominal pain or pelvic pain
• Pain when urinating (dysuria)
• Pain during sexual intercourse (dyspareunia) or ejaculation
• Testicular pain while sleeping (tends to occur in boys)
• Blood in the semen (hematospermia)
• Blood in the urine (hematuria)
• Penile discharge
• Nausea
• Vomiting
• Fever

Many events or medical conditions can cause testicular and scrotal pain in men and boys, including:  

• Trauma. The most common cause of testicular and scrotal pain is trauma. Scrotal trauma does not cause severe injury in most circumstances, although it is usually quite painful. Trauma may result in a bruise or more significant injury. Severe testicular and/or scrotal trauma can occur when a testicle is compressed against the pubic bones either by a direct blow or straddle injury. In some instances, surgery may be necessary.
  
  
• Testicular torsion. Occurs when the testicles and spermatic cord are twisted around inside the scrotum, often cutting off blood supply internally and causing severe pain and swelling. Torsion is the most serious form of testicular injury and should be considered a medical emergency. Though most common in boys aged 12 to 18, it can occur in males of any age. Pain usually appears quickly after physical activity or testicular trauma. In addition to pain in the testicles, torsion may cause nausea and vomiting. It is usually distinguished by a “bell clapper” deformity in which the testes are misaligned.

Irreversible damage to the testes can occur after 12 hours of ischemia (lack of blood flow) resulting from torsion. As a result, immediate exploratory surgery is often necessary to prevent permanent harm. Manual detorsion (untwisting) may be used in cases where surgery is not necessary or readily available. Anyone who suspects he has this condition should seek immediate medical assistance.

• Torsion of the appendix testis. The appendix testis is a piece of tissue attached to the testicle. Its function is not known. If the appendix testis becomes torsed (twisted), it can restrict blood supply and cause intense testicular pain. This injury typically affects young boys. The onset of pain tends to be gradual, with a blue dot often appearing at the site of injury. Torsion of the appendix testis is difficult to diagnose and does not usually occur in conjunction with testicular torsion. The appendix testis may be surgically removed in severe cases.
  

• Epididymitis. The epididymis is a coiled, tube-like structure located in the testicles that aids in the production of sperm. The epididymis can become infected under certain conditions, causing epididymitis. It can occur in two forms:
  
  
• Infectious epididymitis. This occurs when the epididymis becomes infected with bacteria, usually from certain sexually transmitted diseases (STDs) such as chlamydia or gonorrhea. It is more common in younger men and is usually treatable with antibiotics. Although relatively rare, serious illness can occur as a result in some instances. Infectious epididymitis is usually distinguished by severe swelling and pain in the testicles and scrotum. It can be accompanied by symptoms similar to a urinary tract infection, such as high fever or difficulty or pain during urinating (dysuria).
  
  
• Noninfectious epididymitis. Occasionally, epididymitis is caused by unintended urine reflux through the ejaculatory ducts into the epididymis, causing inflammation, swelling and blockage. Noninfectious epididymitis is more common in older men. This condition is typically not serious and is usually treated with common remedies such as anti-inflammatories, rest and scrotal support.   
  
  
• Inguinal hernia. This condition occurs when a part of the intestine bulges through a weakened segment of the groin or abdomen and may enter the scrotum. It is the most common type of hernia in men and can cause extreme testicular pain. A strangulated hernia, in which blood supply to intestinal tissue is constricted, requires immediate medical attention.
  
  
• Testicular vasocongestion. The feeling of temporary aching, heaviness or discomfort in the testicles that can result from sexual arousal without an orgasm. The condition is caused by enlarged, swollen arteries in the scrotum that take several minutes or hours to dissipate after sexual arousal.
  
  
• Post-vasectomy. A vasectomy (a procedure that permanently sterilizes a man) may cause testicular pain at the site of the internal division in some men. Sperm leakage and accumulation may occur within the epididymis, which may cause testicular or scrotal pain. In addition, those who later undergo a vasectomy reversal, which sometimes but not always allows a man to regain fertility, may find this more complicated operation to cause much more pain than their vasectomy did.
  
  
• Orchitis. Inflammation of one or both testicles. It is usually caused by a bacterial infection from STDs. Men without proper mumps vaccinations or who get frequent urinary tract infections can acquire non-sexually transmitted orchitis. Most cases require antibiotic treatment to cure the infection.
  
  
• Prostatitis. Infection and inflammation of prostate gland can cause pain and burning in the scrotal area.
  
  
• Mumps. Adult males with mumps may experience complications including swelling of the scrotum and intense testicular pain. Some men with mumps may also experience orchitis.
  
  
• Swelling. Some men develop pain from testicle or scrotal swelling. This may occur for a number or reasons (e.g., injury, sexually transmitted disease), or the cause may be unknown.
  
  
• Interstitial cystitis (IC). This chronic inflammation of the bladder is far more common in women but also afflicts many men. It can affect the urethra and prostate. Symptoms may include testicular pain, scrotal pain or sexual pain during ejaculation.  
  
  
• Henoch-Schonlein purpura. This disease causes purple skin spots, joint pain and occasional scrotal pain.
  
  
• Fournier’s gangrene. A rare bacterial infection of the skin surrounding the genitals, Fournier’s gangrene occurs when a cut or abrasion becomes infected. It can destroy the surrounding skin, tissue and muscle or even be fatal if it enters the bloodstream..

Referred pain from a condition or injury in a different part of the body can also cause testicular or scrotal pain. For example, passage of a kidney stone down through the urinary system typically causes intense abdominal pain or pelvic pain but can also be experienced as testicular pain. Blood in the urine (hematuria) can also suggest a kidney stone. A urinary tract infection can also cause referred pain in the scrotal area. Tumors or other problems in the spine may also be experienced as referred pain in the testicular area.  

Other types of referred pain that can cause testicular or scrotal pain include:

• Abdominal inflammations. Conditions such as appendicitis, pancreatitis (inflammation of the pancreas), diverticulitis (inflammation of abnormal sacs in the colon) and peritonitis (inflammation of the abdominal membrane) sometimes cause testicular pain in addition abdominal or pelvic pain.
  
  
• Aortic aneurysm. This is a bulging of part of the wall of the aorta, the large artery that directs blood from the heart to the rest of the body. Thoracic (upper back) and abdominal aneurysms seldom produce symptoms but in some cases can cause back pain, abdominal pain or testicular pain. A ruptured aneurysm, an often-fatal medical emergency, is often marked by sudden and severe abdominal or back pain and can also cause severe testicular or scrotal pain.
  
  
• Lymphocytic choriomeningitis. This rodent-borne viral infectious disease presents as meningitis or encephalitis. Symptoms can include fever, malaise, loss of appetite, muscle pain, headache, nausea, vomiting, cough, sore throat, joint pain, chest pain and testicular pain.
  
  
• Familial Mediterranean fever (FMF). This inherited disorder is marked by fever, peritonitis and sometimes scrotal pain that may be severe.

Certain conditions and diseases of the testicles and/or scrotum may indirectly cause testicular and scrotal pain, including:

• Testicular cancer. Although relatively rare, it is the most common form of cancer in men ages 18 to 40. Tumors on the scrotum are usually painless masses often discovered during routine physical examinations. Pain is usually a late symptom of the testicular cancer. However, a rapidly growing tumor can also cause scrotal pain in some cases.
  
  
• Cryptorchidism. This occurs when the testes do not properly descend into the scrotum during fetal development, usually in premature males. It may result in the testes being improperly located in the abdomen or elsewhere, causing discomfort and increasing the risk of testicular cancer. Surgery may be necessary in some cases because cryptorchid testes cannot be put into the scrotum manually. However, the problem often corrects itself by age 1.
  
  
• Varicocele. This term refers to varicose (dilated or swollen) veins in the testicles, and occurs in about 20 percent of post-pubertal males. Varicocele may cause aching scrotal pain while standing or other symptoms (e.g., testicular atrophy, low fertility) and is treated surgically in men hoping to remain fertile. In older men who have finished reproducing and have only minor pain, treatment with anti-inflammatory drugs and scrotal support may be sufficient.
  
  
• Epididymal cysts. An epididymal cyst is a harmless swelling arising from the epididymis (a coiled, tube-like structure aiding in sperm production). Occasionally, these might cause discomfort in the testicular/scrotal area. They can be removed surgically if necessary, although they usually do not require further treatment.
  
  
• Spermatoceles. Cyst-like collections of sperm, usually found in the head of the epididymis. Rarely, they can cause painful symptoms in men. In these instances, surgical removal may be required.
  
  
• Hydroceles. These occur when fluid surrounds a testicle, and are usually painless. In rare instances where pain occurs, surgical removal of the inflamed tissue may be necessary.

Someone experiencing severe testicular and scrotal pain may require care from a physician. Evaluation of acute (sharp or intense) pain begins with a medical history. This is usually followed by a physical examination of the patient, including one or a combination of the following testing procedures:

• Visual examination. A physician usually first visually examines the patient’s penis, abdomen, anus, pubic hair and groin region while the patient is standing. This allows the physician to take into account any physical characteristics (e.g., redness, swelling, piercings, tattoos, skin ulcers) as well as evaluate the position of the testicles.
  
  
• Palpation. This involves feeling for potential irregularities by hand. Palpation is usually painless and is helpful in detecting any swelling or tenderness in the testicular/scrotal area.
  
  
• Cremasteric reflex test. Stroking or pinching of the upper inner thigh will cause the testicles to elevate (cremasteric reflex) in healthy males. A normal response of the cremasteric reflex is usually absent in patients who have experienced testicular torsion (twisting of the testicles and spermatic cord inside the scrotum), which helps distinguish this condition from torsion of the appendix testis (a small piece of tissue attached to the testicle). 
  
  
• Rectal exam. A digital rectal examination (DRE) may be performed to check the prostate gland for prostatitis, benign prostatic hyperplasia or cancer.
  
  
• Urinalysis. Urine is examined for various cells and contents during a urine test. Certain abnormal bacteria may suggest an infection, such as epididymitis, prostatitis or a urinary tract infection.
  
  
• Blood testing. In cases where infection may be suspected, a physician may perform blood tests. Blood and urine tests can also help in in diagnosing kidney stones.
  
  
• Swab test. A swab may be taken from the urethra (tube that discharges urine and semen from the body) when penile discharge is present. A swab test is required to diagnose sexually transmitted infections.

  
  
• Ultrasound. An imaging technology that uses sound waves to produce images of the shape and outline of various tissues and organs in the body. This test is often useful in assessing the severity of certain testicular and scrotal injuries or diseases (e.g., testicular cancer). Ultrasound is used commonly to diagnose testicular torsion.
  
  
• X-ray. This common test may be used to help find the source of referred pain, such as a spine disorder or kidney stones.
  
  
• Radionuclide imaging. This minimally invasive imaging test involves an injection of radioactive dye into the bloodstream. A nuclear scan detects whether the dye is accumulating in the testicle in a healthy manner.

If a man has testicular cancer, imaging tests such as a CAT scan, MRI or PET scan may be used to reveal whether the cancer has spread elsewhere. A CAT scan may also be used in detection of kidney stones.

Treatment for testicular and scrotal pain varies depending on the cause and severity of the pain. Some relief options include:

• Rest. Taking time to rest following a testicular/scrotal injury or procedure is often a sufficient remedy in cases where pain is relatively moderate.
  
  
• Elevation. Elevation of scrotum by using support after testicular/scrotal injury or procedure often alleviates mild to moderate pain.
  
  
• Cryotherapy (cold treatment). Applying an ice bag or cold pack to the scrotum can help relieve pain and swelling. They can also increase the time a testicle can survive with decreased blood flow in cases of severe injury, such as torsion.
  
  
• Pain medicines. Nonsteroidal anti-inflammatory drugs such as ibuprofen or aspirin may help reduce pain temporarily. 
  
  
• Surgery. In cases of serious injury or disease, surgery may be required to prevent further damage and begin recovery. The success of surgery in these instances may vary according to various factors (e.g., time between injury/diagnosis and surgery).
  
  
• Manual detorsion. If surgery for torsion injuries is not available, manual detorsion of the testicle may be necessary. This is performed by rotating the testicle in a manner opposite to the initial injury. Exploratory surgery may be necessary after manual detorsion is completed to check for remaining complications.
  
  
• Antibiotics. These may be used to help alleviate pain when a bacterial infection is present.

Some types of testicular and scrotal pain, such as torsion of a testicular appendage, can be treated with ice and pain medication and generally resolve within a week. Other conditions, however, require specific types of treatment. These include:

• Torsion. Often requires immediate surgery or an attempt to untwist the testicle for temporary pain relief.
  
  
• Epididymitis. Often requires antibiotic treatments for seven to 10 days. Occasionally, a hospital stay is required with this condition.
  
  
• Hernia. Usually requires surgery.
  
  
• Tumor. Individuals with a testicular tumor are usually referred to a urologist or oncologist for treatment.
  
  
• Rupture or hematocele. This condition often requires immediate surgery to resolve the problem.
  
  
• Kidney stones. Drinking plenty of water usually helps small stones pass through the urinary tract. In some cases, however, kidney stones require medication, shockwave therapy (lithotripsy) or surgery.

Individuals who have had surgery for testicular torsion or a hernia should have a follow-up meeting or consultation with their surgeon. Those patients who have received treatment for epididymitis or torsion of a testicular appendage seek additional medical attention if any of the following should occur:

• Symptoms persist for longer than one week
• Pain increases
• Symptoms appear to change

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about testicular and scrotal pain:

1. What is the cause of my pain?
   
   
2. What diagnostic tests might I have to undergo?
   
   
3. Do I need surgery to treat my pain?
   
   
4. Will I have any permanent damage?
   
   
5. Can my condition lead to sterility or impotence?
   
   
6. If I am at risk of becoming infertile or impotent, how can I reduce these odds?
   
   
7. Should I be checked for testicular, scrotal and prostate conditions whenever I have a physical examination?
   
   
8. Should I be tested for sexually transmitted diseases or testicular cancer?
   
   
9. How can I distinguish testicular torsion from a testicular injury I can treat at home?
   
   
10. What protective clothing and gear should I wear when I play sports or do strenuous work?
    
    
11. Will I experience testicular and scrotal pain more often as I age?
    
    
12. What can I do to minimize my risk of testicular and scrotal pain?