What is Acute Scrotum Pain?
Acute scrotum pain refers to sudden, new pain, swelling, or tenderness in the scrotum area. The symptoms can happen within a matter of minutes or over the course of 1 to 2 days, depending on what’s causing it. This term is used to describe a range of different health conditions. It’s critical to quickly figure out the cause and start treatment because some conditions, like a twisted testicle, are serious but can be fixed if taken care of promptly.
Understanding the structure of the male reproductive organs is important to diagnose and treat acute scrotum pain. The testes are oval organs, about 3 cm to 5 cm long, 3 cm wide and thick, that sit vertically. A protective covering called the tunica albuginea surrounds the testes. The epididymis, which is curved and about 6 cm to 7 cm long, is located next to the testes. It connects to form the ductus epididymis and then the vas deferens, which are tubes for sperm to travel through.
The blood supply to the testes is important as well. The testicular artery, deferential artery, and cremasteric artery all bring blood to the testes. The testicular artery comes directly from the main blood vessel in your body, the abdominal aorta. The blood then leaves the testes through small veins called the pampiniform plexus that form the testicular vein. This vein drains into the big vein in your body, the inferior vena cava, on the right, and into the left kidney vein on the left.
All these vessels, the vas deferens, and nerves are enclosed in the spermatic cord, a structure that connects your abdomen to your scrotum. The cremaster muscle is also part of this cord. The tunica vaginalis typically only covers part of the testis and epididymis and then attaches to the back of the scrotum. However, sometimes it covers the testis and part of the spermatic cord, allowing the testicle to rotate freely. This condition, known as the Bell-Clapper deformity, can happen in up to 12% of people.
What Causes Acute Scrotum Pain?
Sudden severe pain in the scrotum can be caused by various things. These causes range from issues linked with blood supply or injury, to infections and inflammation, or even misunderstood pain from other areas. It can be either sudden or gradual, or have unclear causes. The situation is similar to patients showing up with a sudden severe belly pain.
It’s challenging to categorize these causes since many have long-term aspects but can present suddenly. Inguinal hernias, for example, may not have any symptoms until they’re blocked or squeezed, at which point they produce sudden severe pain.
Here’s a representative list of causes,
Issues with blood supply or injury:
- Twisting of the testes
- Twisting of appendages on the testes
- Blood accumulation in the testes
- Blocked varicocele (an enlarged vein)
- Obstructed or pinched hernia in the groin or scrotum
Infection or inflammation-related causes:
- Inflammation of the epididymis (tube at the back of the testicle)
- Inflammation of both the epididymis and testicle
Pain from other regions or nerve-related causes:
- Stone in the middle of the urethra
- Blocked or pinched hernia in the groin
- Aneurysm in the aorta or common iliac artery
- Pinched nerve
- Nerve damage due to diabetes (this often shows up over a longer period)
- Sexual abuse
The most familiar causes are inflammation in the epididymis alone or with the testes, twisting of the testes or appendages, varicoceles, and blocked or squeezed inguinal hernias. The frequency of these causes can change noticeably with age. In children, sudden severe pain in the scrotum is more likely from twisting of the testes or its appendages. Whereas, older patients, above 25 years, are more likely to suffer from inflammation of the epididymis.
Risk Factors and Frequency for Acute Scrotum Pain
While there isn’t much specific information about how often the acute scrotum is the main issue for patients, we do know that complaints about the male reproductive system make up between 0.5% and 2.5% of all emergency department visits. Testicular torsion, or twisting of the spermatic cord, happens to about 1 in 4000 men every year. This means that 1 in 160 men experience this issue before they turn 26, with the chances dropping significantly as men get older.
Interestingly, even though it’s possible among all age groups, for children, the common cause of acute scrotal pain is usually not due to the spermatic cord, but rather the torsion of the appendix testis.
On the other hand, the most common cause of acute scrotal pain in adults is epididymitis. Every year, it’s estimated that over 600,000 cases are diagnosed in U.S. emergency departments. This issue is so common that it’s responsible for one out of every 144 outpatient visits for men aged 18 to 50. The occurrence of this condition tends to have two peak periods, due to differing causes and risk factors.
Signs and Symptoms of Acute Scrotum Pain
When examining a patient with acute scrotum, which refers to sudden pain in the testicles, understanding their medical history and conducting a thorough physical examination is critical. The doctor needs to know when the symptoms started, how long they’ve lasted, and if they were constant or sporadic. They should also inquire about any recent strenuous activities, trauma, and changes like swelling, discharge, reddening, rashes, or colour changes. Associated symptoms like fever, painful urination, frequent urge to urinate, blood in semen, abdominal or back pain, or weight loss should also be asked about. Other important queries include the patient’s history with regards to diseases like diabetes and heart failure, their immune health status, and their sexual history.
As a part of the physical examination, the doctor should visually inspect the fully exposed abdomen, groin, penis, and scrotum, looking for any abnormal features like rashes, lesions, irregular scrotal symmetry, or unusually-positioned testicle. Checking the scrotum, perineum, and thighs by touch, to identify any abnormalities like crepitance (a crunching sensation) or subcutaneous emphysema (bubble-like lumps under the skin) is also important. Palpating the scrotal contents can help identify any inconsistencies in testes size, masses, or hernias. Checking the urethra for any discharge and investigating the presence of a cremasteric reflex, a natural upward pulling of the testes, are also part of the examination.
- The onset and duration of symptoms should be considered
- Factors like recent strenuous activities or trauma should be considered
- Changes like swelling, discharge, reddening, rashes, or skin colour changes should be noted
- Associated symptoms like fever, painful urination, frequent urination, blood in semen, abdominal or back pain, or weight loss should be checked
- The patient’s history of diseases like diabetes and heart failure, their immune health status, and their sexual history should be reviewed
- A thorough physical examination, including visual inspection and palpation, should be conducted
- The presence of a cremasteric reflex should be determined
Acute testicular torsion, a condition where the spermatic cord twists and cuts off the blood supply to the testicle, is usually characterized by a noticeably misplaced “high-riding” testicle and loss of the natural upward pulling of the testes, the cremasteric reflex. If lifting the affected testicle relieves pain, it suggests epididymitis, an inflammation of the tube at the back of the testicle. But if there’s no pain relief, it indicates testicular torsion. However, these signs are not always seen and might lead to incorrect or delayed treatment. The cremasteric reflex may be absent in about 30% of healthy males, and some patients with confirmed testicular torsion might still have the reflex. Other scrotal conditions might also lead to loss of the reflex.
Testing for Acute Scrotum Pain
In the evaluation of spermatic cord torsion, a condition that could lead to the twisting of the testicles, getting a detailed history and physical examination is the first step. If this condition is suspected, an urgent consultation with a surgeon is recommended. In such cases, swift surgical intervention is crucial as the chances of preserving the testicle’s function drop significantly with time. While a guideline suggests surgical repair within six hours of symptoms, it doesn’t mean patients who’ve had symptoms for more than six hours should be delayed – immediate evaluation and surgery are still needed. However, it’s important to note that success rates of surgery drop to 80% – 88% at 12 hours, 31% at 24 hours, and as low as 2.6% at 48 hours.
If further examination doesn’t delay urgent surgical consultations, your doctor may recommend additional tests. This could include complete blood counts, urine tests, and swabs for sexually transmitted infections like gonorrhea and chlamydia. For patients who appear very ill or show signs of sepsis, it might be necessary to carry out blood cultures, check inflammatory markers, and arrange cross-sectional imaging of the pelvis and thighs.
Color Doppler Ultrasound is often the best imaging choice for evaluating testicular problems when it won’t delay an urgent consultation with a surgeon. These ultrasounds are able to detect whether blood flow to the area is normal with a high level of accuracy. They can show an enlarged, less echo-producing testicle, absent blood flow, or a twisted spermatic cord – a pattern sometimes described as the “whirlpool” or “snail” sign.
The ultrasound can also show whether an infection is causing the problem, as infections often increase blood flow to the testicle or epididymis. In this instance, the testicle or epididymis may appear enlarged on the ultrasound. It can also identify abscesses or signs of gas within the scrotal wall.
There are other kinds of imaging tests, but they have their limitations. For example, scrotal imaging using radioactive substances was once a popular tool with a good record for differentiating between testicular torsion and an infection of the epididymis. However, it’s more likely to give a false positive result and prompt unnecessary surgery compared to modern ultrasound techniques.
MRI has high accuracy in detecting torsion but may not be practical due to availability and time constraints. CT scans are mainly useful when there’s a concern for severe skin and soft tissue infections or Fournier gangrene, a life-threatening bacterial infection of the genitals.
Treatment Options for Acute Scrotum Pain
The best way to treat testicular torsion, a condition where the testicle twists and cuts off blood supply, is through surgical intervention. This typically involves an exploratory procedure to untwist the testicle, followed by a surgical procedure to attach the testicle to the scrotum to stop it from twisting again.
Sometimes, healthcare professionals can try to untwist the testicle manually. However, the success of this method varies widely – it can work anywhere from 25% to 80% of the time. If the testicle has twisted towards the middle of the body, the untwisting should be attempted first from the middle towards the side, which is similar to the action of opening a book.
To be specific, this means rotating the right testicle counterclockwise, or the left one clockwise. This manual approach is not advisable if there has been pain or signs of torsion for over 6 hours.
Point-of-care ultrasound, a device used at the patient’s bedside for immediate results, can be used to check the direction of testicular torsion and whether the manual untwisting is effective. If this maneuver is successful, the patient should feel relief almost instantly. However, even if the manual untwisting is successful, surgery is still needed.
The treatment for epididymitis, an inflammation of the tube at the back of the testicle that stores and carries sperm, is discussed elsewhere and entails antibiotic therapy aimed at the most likely cause of the infection.
What else can Acute Scrotum Pain be?
When there’s a medical issue, doctors have to consider many different conditions that might be the cause. For instance, in cases of testicular or scrotal problems, doctors might need to consider:
- Acute epididymitis or epididymo-orchitis (inflammation of the epididymis)
- Torsion of a testicular appendage (twisted tissue in the testicles)
- Spermatic cord torsion (twisted spermatic cord, which can cut off blood supply)
- Henoch-Schonlein purpura (a disease that causes blood vessels to become inflamed)
- Strangulated or incarcerated hernia in the groin area
- Varicocele (enlarged veins in the scrotum)
- Scrotal cellulitis (a bacterial skin infection)
- Fournier’s gangrene (a serious infection of the genital area)
- Unexplained swelling in the scrotum
- Bleeding inside the testicles
- Scrotal or testicular abscess (a pocket of pus)
- Infarction of the testicles (tissue death due to lack of blood flow)
- Tumour in the testicles
- Tear or damage to the testicles
It’s crucial that the doctor understands the patient’s symptoms and medical history, and performs appropriate tests, to correctly identify the root of the problem.
What to expect with Acute Scrotum Pain
The outcome for acute pain in the scrotum varies depending on its root cause. For patients dealing with epididymitis, an inflammation of the tube at the back of the testicle, the pain usually improves within a few days after starting treatment, but the swelling might persist for weeks or even months.
In some cases, especially in individuals with diabetes, an abscess or a pocket of pus can develop, which can lead to a severe infection spreading in the body, known as sepsis. It’s worth noting that in cases where epididymitis is as a result of sexual activity, it’s important to refer and treat the sexual partner too, to halt the spread of the infection.
For those diagnosed with testicular torsion – a condition where a testicle becomes twisted, cutting off blood supply – quick diagnosis and treatment are crucial. If treatment is delayed for anywhere between 12 to 24 hours, it greatly increases the likelihood of losing the testicle and becoming infertile.
Possible Complications When Diagnosed with Acute Scrotum Pain
If there is a delay in diagnosing or treating a greatly damaged testicle, it can lead to a number of complications. The damaged testicle could become gangrenous if not removed in time, meaning it decays due to lack of blood supply. If infection occurs, it can spread throughout the body via the bloodstream, leading to a condition called septicemia. If both testicles are damaged, it could lead a man to not be able to father a child.
If a testicle has to be removed (also known as an orchidectomy), the man may experience a change in his physical appearance. To address this, a testicular prosthesis, which is a fake testicle, can be inserted.
- Possible complications from delay in treatment
- Gangrenous testicle if not removed
- Septicemia if infection spreads to bloodstream
- Infertility if both testicles are damaged
- Change in physical appearance after orchidectomy
- Potential use of testicular prosthesis
