Overview
Testicular pain ranges from mild discomfort to severe acute pain requiring emergency assessment. The most important cause to exclude is testicular torsion, where the testicle twists on its blood supply, requiring surgery within 6 hours to save the testicle. Other common causes include epididymo-orchitis (infection) and minor trauma. Any unexplained testicular pain should be medically assessed.
How common is it?
Testicular pain accounts for approximately 1% of all male GP consultations. Epididymo-orchitis is the most common cause in adults over 35. Testicular torsion is most common in adolescent boys (peak age 13 to 16) but can occur at any age.
Causes and risk factors
The testis, epididymis, and surrounding structures have several causes of pain. Emergency causes must be excluded first.
Common risk factors
- Testicular torsion: spontaneous twisting of the spermatic cord cutting off blood supply — requires surgery within 6 hours
- Epididymo-orchitis: bacterial infection from STIs (Chlamydia in under 35s) or urinary tract organisms (over 35s)
- Torsion of the testicular appendix: twisting of a small embryological remnant — benign but painful
- Trauma: direct blow to the testis
- Varicocele: dilated veins in the scrotum causing dull ache
- Hydrocele: fluid accumulation around the testis
- Testicular cancer: typically painless but may cause discomfort
- Referred pain from kidney stones, inguinal hernia, or lumbar nerve root compression
Symptoms
- Sudden severe testicular pain (torsion — surgical emergency)
- Gradually developing pain with swelling and redness (epididymo-orchitis)
- Dull ache that worsens throughout the day or with prolonged standing (varicocele)
- Pain after trauma
- A smooth swelling above the testis that transilluminates (hydrocele)
- A firm, painless lump within the testis (until proven otherwise: testicular cancer)
When to see a doctor
Any sudden severe testicular pain must be treated as torsion until proven otherwise. Go to A&E immediately. Do not wait to see if it improves. Time is testis: salvage rates drop from 100% within 6 hours to under 10% after 24 hours.
Diagnosis
Testicular torsion: clinical assessment. Doppler ultrasound confirms absent blood flow (torsion) vs increased flow (orchitis) but must not delay surgery if torsion is clinically suspected. Urine and urethral swabs for STIs.
Treatments
Emergency surgical detorsion
Immediate surgical exploration for suspected testicular torsion. Both testicles are fixed to prevent future torsion (orchidopexy), as the contralateral side may have the same anatomical predisposition.
Antibiotics for epididymo-orchitis
STI-related (under 35): doxycycline 100mg twice daily plus ceftriaxone 500mg IM single dose. Non-STI urinary infection (over 35): ciprofloxacin 500mg twice daily or levofloxacin 500mg once daily for 2 to 4 weeks.
Supportive care
Scrotal support, NSAID analgesia, and rest for orchitis and trauma. Varicocele treatment (embolisation or surgery) for symptomatic varicoceles, particularly if affecting fertility.
Self-care and lifestyle
- Never dismiss sudden acute testicular pain as minor — always seek immediate assessment
- Monthly testicular self-examination to detect changes early
- Wear protective cups during contact sports
Prevention
No reliable prevention for torsion (though orchidopexy of the contralateral testis at the time of detorsion is protective). STI prevention reduces epididymo-orchitis risk.