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acute scrotal pain or swelling


  • adolescents and young adults with acute onset of testicular pain and tenderness should be regarded as a surgical emergency with possible torsion of testes as infarction of the testes increases with duration and poor prognoses if duration exceeds 4 hours.
  • testicular survival rates approach zero after 24 hours of torsion.
  • ultrasound should NOT be done in children and young men who have an acute scrotum of less than 24 hours duration as it may be incorrect and, more importantly, delays theatre, and any delay reduces chances of survival of testes with each hour if it is a torsion
  • in children and those adults under age 40 years, the surgical team should be notified immediately of any patient with possible torsion testis

torsion testis

torted scrotal appendage

  • 90% of boys have an appendix testis (Hydatid of Morgagni) which is an embryological remnant of the Mullerian duct and is a gelatinous vascular connective tissue structure
  • this and other appendages such as paradidymis (Organ of Giraldes) and vas aberrans of Haller, may undergo torsion resulting in severe pain and subsequent swelling and oedema which lasts 1-2 weeks if left untreated
  • torsion mainly occurs in prepubertal boys
  • onset of pain is less rapid than it is for testicular torsion
  • a blue spot at the top of the testicle may be visible
  • local tenderness is at the torted structure rather than the testes itself
  • Mx is usually surgical as conservative Mx results in a hydrocele and further assessment to exclude torsion of testis becomes difficult.

inguinal hernia

referred pain


  • engorgement of the testicular vein and pampiniform plexus
    • usually more severe on the left side (98% of primary cases present on the left side) as:
      • left vein drains into the left renal vein while the right vein drains into the IVC
      • the angle at which the left testicular vein enters the left renal vein
      • lack of effective antireflux valves at the juncture of the testicular vein and renal vein
      • the increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (ie. “nutcracker effect”).
  • primary varicoceles:
    • occurs in 15-20% of all males, usually first presenting at age 15-30 years
    • occurs in 40% of infertile males presumably as it impairs testicular thermoregulation and is the most common cause of infertility
    • 35-40% with a left varicocele actually have bilateral varicoceles clinically (perhaps 80% when radiologic testing is done)
  • secondary varicoceles
    • these are caused by external compression of the testicular vein such as by:
      • “nutcracker effect” of the SMA and aorta
        • this condition may also cause left flank pain and even left sided haematuria due to obstruction of left renal vein causing development of collateral veins with intrarenal and perirenal varicosities which can cause hematuria if the thin-walled septum separating the veins from the collecting system ruptures1)
      • pelvic or abdominal masses such as malignancies, especially renal malignancies - particularly a concern if a new diagnosis of a right sided varicocele in a man aged over 40 years
      • retroperitoneal fibrosis or adhesions
  • most are asymptomatic
  • acute symptoms may be precipitated following prolonged erections and perhaps is the cause of the sensation of what is colloquially known as “MSB”
  • testes feels like a bag of worms
    • large ones are visible
    • moderate ones are palpable
    • small ones are palpable only when patient bears down
  • painful episodes partly relieved by lying down, worse on standing, and generally settle within a few hours
  • surgery is thought to improve fertility in 1 in 7 men

intrascrotal infection



  • rare as most are vaccinated
  • usually causes bilateral tender swollen scrotum

bacterial infections

scrotal skin pathology

  • idiopathic scrotal oedema
    • mainly 9-18 month olds
  • scrotal cellulitis
  • scrotal abscess
  • insect bite
  • Fournier gangrene
    • a life threatening form of necrotizing fasciitis involving the perineum or scrotum +/- penis, usually seen in older men who are diabetic, immunocompromised or have substance abuse or mental health / hygiene issues
    • presents with fever and acute pain and rapidly progresses to a black necrotic area of skin +/- malodour +/- pus +/- crepitus
    • males 40 x females and is usually due to a synergistic polymicrobial infection
    • requires early IV antibiotics and emergent debridement in theatre as mortality rates can be high


  • bruise
  • haematocele
    • generally are explored surgically as risk of ischaemia of testes due to pressure
  • ruptured testicle


scrotal_pain.txt · Last modified: 2018/12/04 07:56 by

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