Scrotal Swelling

ection Editors:
Amy B Middleman, MD, MPH, MS Ed

Gary R Fleisher, MD
Laurence S Baskin, MD, FAAP
Deputy Editor:
James F Wiley, II, MD, MPH
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Aug 2019. | This topic last updated: Feb 25, 2019.
INTRODUCTIONThe clinical presentation, diagnosis, and management of hydrocele,

varicocele, spermatocele will be discussed below along with the presentation and diagnosis of
testicular cancer.
Inguinal hernia, the evaluation of scrotal pain and swelling, and the causes of scrotal pain in
children and adolescents are discussed separately. (See "Inguinal hernia in children" and
"Evaluation of scrotal pain or swelling in children and adolescents" and "Causes of scrotal
pain in children and adolescents".)
BACKGROUNDThe spectrum of conditions that affect the scrotum and its contents ranges
from incidental findings to pathologic events that require expeditious diagnosis and treatment
(eg, testicular torsion, testicular cancer).
The most common causes of painless scrotal swelling in children and adolescents include
hydrocele and inguinal hernias that are not incarcerated. Less common causes are varicocele,
spermatocele, localized edema from insect bites, nephrotic syndrome (swelling is usually
bilateral), and rarely, testicular cancer (table 1). Scrotal swelling and testicular masses
warrant prompt evaluation.
HYDROCELEA hydrocele is a collection of peritoneal fluid between the parietal and visceral
layers of the tunica vaginalis. Hydroceles may be communicating or noncommunicating.
Communicating hydroceles usually develop as a result of failure of the processus vaginalis to

close during development; the fluid around the testis is peritoneal fluid (figure 1 and picture
1) [1]. Noncommunicating hydroceles have no connection to the peritoneum; the fluid comes
from the mesothelial lining of the tunica vaginalis (figure 2).
Hydroceles are common in newborns (whether related to delayed closure of a patent

processus vaginalis or fluid trapped at the time of testicular descent is not known) [1]. The
majority of hydroceles in neonates resolve spontaneously, usually by the first or second
birthday [2-4].
In older children and adolescents, noncommunicating hydroceles may be idiopathic or may

occur secondary to epididymitis, orchitis, testicular torsion, torsion of the appendix testis or
epididymis, trauma, or tumor (reactive hydroceles). These conditions must be excluded in
children and adolescents with hydrocele. (See "Evaluation of scrotal pain or swelling in
children and adolescents" and 'Testicular cancer' below.)
Clinical presentation — Patients with hydroceles present with a cystic scrotal mass. A
hydrocele that communicates with the peritoneal cavity may increase in size during the day or
with the Valsalva maneuver. In contrast, noncommunicating hydroceles are not reducible and
do not change in size or shape with crying or straining. Although rare, large,
noncommunicating hydroceles may extend through the inguinal ring and into the abdomen
creating an abdominal scrotal hydrocele. This condition is suspected when abdominal
extension of the hydrocele into the abdominal cavity is present on examination and confirmed
by sonogram (picture 2) [5].
In patients with testicular pain and scrotal swelling, the hydrocele may arise from
epididymitis, orchitis, testicular torsion, torsion of the appendix testis or appendix
epididymis, testicular rupture, testicular hematoma, or tumor as the primary etiology (reactive
hydroceles); Doppler ultrasonography is usually necessary to evaluate these patients further.
(See "Evaluation of scrotal pain or swelling in children and adolescents" and 'Testicular
cancer' below.)
Diagnosis — The diagnosis of hydrocele can be made by physical examination and

transillumination of the scrotum that demonstrates a cystic fluid collection. Communicating
hydroceles are often reducible; noncommunicating hydroceles are not. Doppler
ultrasonography may be necessary to evaluate the testicle and rule out a primary cause or to
determine if an abdominoscrotal hydrocele is present.
Management — Surgical repair is indicated for communicating hydroceles that persist

beyond one to two years of age and for idiopathic, noncommunicating hydroceles that are
symptomatic or compromise the skin integrity [2,4].
The management of asymptomatic hydroceles in a neonate or child younger than one to two
years of age usually is supportive [2,6]. Hydroceles that are present in newborns, whether
communicating or noncommunicating, usually resolve spontaneously by the second birthday,
unless they are accompanied by an inguinal hernia or are large [1,6]. (See "Inguinal hernia in
children".)
Communicating hydroceles in patients older than two years of age rarely resolve and pose a
risk for development of incarcerated inguinal hernia. Surgical repair of communicating
hydroceles is usually undertaken on an elective basis [6-8].
Idiopathic noncommunicating hydroceles are often asymptomatic. Surgical repair may be

indicated for symptomatic complaints and for abdominal scrotal hydroceles [5].
Reactive hydroceles usually resolve with treatment of the underlying condition. (See
"Inguinal hernia in children" and "Causes of scrotal pain in children and adolescents" and
"Clinical manifestations, diagnosis, and staging of testicular germ cell tumors".)
INGUINAL HERNIAAn inguinal hernia that is not incarcerated typically presents with a
nontender reducible mass. Its size increases with a Valsalva maneuver, and it does not
transilluminate. The clinical presentation, diagnosis, and management of inguinal hernia in
children are discussed separately. (See "Inguinal hernia in children".)
VARICOCELEA varicocele is a collection of dilated and tortuous veins in the pampiniform

plexus surrounding the spermatic cord in the scrotum (figure 3). The cause of primary or
idiopathic varicoceles, that arise spontaneously and are not caused by obstruction of the
inferior vena cava, is unknown. One etiologic theory is that primary varicoceles result from
increased venous pressure and incompetent valves [7,9-11]. Varicoceles occur more
commonly on the left side (85 to 95 percent) because the left spermatic vein enters the left
renal vein at a 90 degree angle, whereas the right spermatic vein drains at a more obtuse
angle directly into the inferior vena cava, facilitating more continuous flow (figure 4)
[7,9,10]. Approximately 10 to 25 percent of all adolescent males and as many as one-third of
all males examined at an infertility clinic have a varicocele. However, only 10 to 15 percent
of males with varicoceles have fertility problems [10].
Clinical presentation and diagnosis — Patients with varicoceles can be asymptomatic or

present complaining of a dull ache in or fullness of the scrotum upon standing. The key task
for the examiner is to differentiate primary varicocele from secondary varicocele caused by
obstruction of the inferior vena cava.
The examination for varicocele initially should be performed with the patient standing [12].
The scrotum is inspected for any visible distention around the spermatic cord (indicative of a
grade III varicocele). The scrotum, testes, and cord structures are then gently palpated; a
palpable varicocele has the texture of a "bag of worms" (figure 3). Grade II varicoceles are
palpable, but nonvisible. The patient should then be asked to perform the Valsalva maneuver;
if the varicocele is palpable only with the Valsalva maneuver, it is Grade I (table 2).
The patient also should be examined in the supine position [12]. This maneuver will help to
differentiate idiopathic or primary from secondary varicocele. Primary varicocele usually is
more prominent in the upright position and disappears in supine, whereas secondary
varicocele usually does not get much smaller with change in position from upright to supine.
If the varicocele persists in the supine position, has acute onset, or is right-sided (secondary
varicocele), then processes that cause inferior vena caval (IVC) obstruction must be ruled out
with Doppler ultrasonography [9]. These processes include:
●IVC thrombus
●Right renal vein thrombosis with clot propagation down the IVC
●Abdominal mass (eg, retroperitoneal tumors, kidney tumors, or lymphadenopathy) [13]
Varicocele grade does not correlate well with abnormal semen analysis or infertility in adults
[14]. Studies in adolescents correlating varicocele grade and testicular size in adolescents
have had conflicting results [15-18]. Elevations in unstimulated luteinizing hormone and
follicle stimulating hormone concentrations may be more predictive but should only be
obtained after consultation with a urologist [19].
Management — There are no clear guidelines established for treatment of a varicocele in

childhood [20]. Referral to an urologist is indicated for patients with pain, decreased testicle
size, or large varicocele. Most varicoceles in adolescents are managed conservatively with
observation. When more aggressive treatment is necessary, varicoceles are repaired through
surgical ligation or testicular vein embolization. Based upon a systematic review of 12 trials
and 39 case series, these procedures may be warranted under the following circumstances
[20,21]:
●Affected testicular volume is less than that of the unaffected testicle (a difference in size of
>10 to 15 percent or >2 mL when assessed by ultrasonography) because loss of testicular
volume is associated with a decreased sperm count and testicular growth arrest can be
reversed with varicocele repair.
●To alleviate symptoms such as pain, heaviness, or swelling.
●Bilateral varicoceles.
●When obtained, abnormal seminal fluid analysis.
Although grade of varicocele should not be the sole indication for intervention, treatment
may be warranted in adolescents with large varicoceles (grade III) and abnormal semen
analysis because varicocele repair has been associated with improved semen analysis in
adolescents and young men. However, improved fertility and paternity after surgical
treatment of varicoceles in adolescents has not been clearly established [21].
SPERMATOCELE (EPIDIDYMAL CYST)A spermatocele (epididymal cyst) is a painless,

fluid-filled cyst of the head (caput) of the epididymis that may contain nonviable sperm
(figure 5). A spermatocele can be palpated as distinct from the testis and typically
transilluminates as a cystic mass. In contrast, testicular tumors are palpated within the testis
and do not transilluminate. Ultrasonography may be helpful to confirm the diagnosis of
spermatocele. Spermatoceles do not affect fertility. Treatment (eg, surgical excision) is
indicated to relieve discomfort.
TESTICULAR CANCERTesticular cancer accounts for 20 percent of cancer diagnosed in

males 15 to 35 years old, rendering it the most common solid tumor in males within this age
group [22,23]. The epidemiology and risk factors for testicular cancer, which include
cryptorchidism, family history of testicular cancer, cancer of the other testicle, human
immunodeficiency virus (HIV) infection, germ cell neoplasia in situ (GCNIS, formerly called
intratubular germ cell neoplasia of the unclassified type [24]), and race, are discussed in
detail separately. (See "Epidemiology of and risk factors for testicular germ cell tumors".)
Clinical presentation — Testicular cancer usually presents as a painless mass discovered by

the patient or clinician on physical examination, although rapidly growing germ cell tumors
may cause acute scrotal pain secondary to hemorrhage and infarction. Other common signs
are testicular enlargement or swelling. Many patients also report an aching feeling in the
lower abdomen or scrotum.
On examination, intrascrotal malignancies usually are firm, nontender masses that do not
transilluminate. Some patients may have gynecomastia. The clinical presentation of testicular
cancer and advanced or metastatic testicular cancer are discussed in more detail separately.
(See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors".)
Diagnosis — Scrotal ultrasound is the initial diagnostic test of choice [22,25]. Although
pathology is the definitive diagnostic test, scrotal ultrasound may help to distinguish intrinsic
from extrinsic testicular lesions. (See "Clinical manifestations, diagnosis, and staging of
testicular germ cell tumors".)
Several conditions may mimic neoplasia on ultrasound, including inflammation, hematoma,
infarct, fibrosis, and tubular ectasia of the rete testis. In cases in which the ultrasound is
inconclusive, magnetic resonance imaging (MRI) may help differentiate benign from
malignant lesions. This was illustrated in a study of 622 patients who underwent ultrasound
examination to evaluate a variety of scrotal diseases, of whom 17 had a lesion suspicious for
cancer but an inconclusive ultrasound [26]. No lesion defined as benign by MRI proved to be
malignant (negative predictive value 100 percent), although two benign inflammatory lesions
were mistakenly thought to be malignant (positive predictive value 71 percent). These
findings suggest ultrasound is sufficient in the vast majority of patients with suspected
malignancy on examination, but MRI is a useful adjunct when the ultrasound result is
equivocal.
Boys with lesions that are consistent with cancer should be referred to a urologist for
diagnostic evaluation, which may include blood tests for various tumor markers, and radical
inguinal orchiectomy. (See "Clinical manifestations, diagnosis, and staging of testicular germ
cell tumors".)
Management — The treatment of testicular cancer is discussed separately. (See "Overview of

the treatment of testicular germ cell tumors".)
Early detection — Prevention of testicular cancer centers on improved awareness and early
detection (eg, secondary prevention). Efforts to increase awareness of testicular cancer can
occur in the general community (eg, Lance Armstrong Foundation [www.livestrong.org]), in
schools, and at medical visits.
Screening for testicular cancer is discussed in greater detail separately. (See "Screening for
testicular cancer".)
OTHER CAUSES
●Insect bites – Localized edema from insect bites may cause scrotal swelling; such swelling
may be accompanied by erythema and/or pruritus.
●Nephrotic syndrome – The nephrotic syndrome is characterized by nephrotic range

proteinuria, hypoalbuminemia, edema, and hyperlipidemia. The edema is gravity dependent.
(See "Etiology, clinical manifestations, and diagnosis of nephrotic syndrome in children".)
●Acute leukemia or lymphoma – Although rare, painless unilateral testicular enlargement can
be a presenting sign of acute lymphocytic leukemia or lymphoma. (See "Overview of the
clinical presentation and diagnosis of acute lymphoblastic leukemia/lymphoma in children",
section on 'Presentation'.)
●Other conditions producing generalized edema due to hypoproteinemia or increased

hydrostatic pressure (eg, protein losing enteropathy, hepatic cirrhosis).
INFORMATION FOR PATIENTSUpToDate offers two types of patient education materials,

"The Basics" and "Beyond the Basics." The Basics patient education pieces are written in
plain language, at the 5th to 6th grade reading level, and they answer the four or five key
questions a patient might have about a given condition. These articles are best for patients
who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Hydrocele (The Basics)" and "Patient education:
Varicocele (The Basics)")
SUMMARY
●The most common causes of painless scrotal swelling in children and adolescents include
hydrocele and inguinal hernias that are not incarcerated. Less common causes include
varicocele, spermatocele, localized edema from insect bites, nephrotic syndrome, and rarely,
testicular cancer (table 1). Scrotal swelling and testicular masses should be evaluated
promptly. (See 'Introduction' above.)
●A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the
tunica vaginalis (figure 2). Hydroceles may occur in reaction to testicular torsion, tumor,
epididymitis, orchitis, or trauma; these conditions must be ruled out by palpation of the entire
testicular surface and/or ultrasonography. Such reactive hydroceles usually resolve with
treatment of the underlying condition. Surgical repair of hydroceles is indicated for
hydroceles in newborns that persist beyond one year of age, for communicating hydroceles,
and for idiopathic hydroceles which are symptomatic. (See 'Hydrocele' above.)
●A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus

surrounding the spermatic cord (figure 3). Inferior vena caval obstruction must be excluded in
patients with varicocele if the varicocele persists in the supine position, has acute onset, or is
only right-sided. (See 'Varicocele' above.)
●A spermatocele (epididymal cyst) is a painless, fluid-filled cyst of the head (caput) of the
epididymis that may contain nonviable sperm (figure 5). Spermatoceles do not affect fertility
and rarely require excision. (See 'Spermatocele (epididymal cyst)' above.)
●Testicular cancer usually presents as a painless mass in the testicle that is firm and
nontender; it may be accompanied by a reactive hydrocele. Such masses must be evaluated
promptly. Scrotal ultrasonography is the initial diagnostic test of choice; boys with lesions
that are consistent with cancer should be referred to an urologist for additional evaluation.
(See 'Testicular cancer' above.)
●Boys with a history of cryptorchidism, previous testicular cancer, HIV infection,

intratubular germ cell neoplasia of the unclassified type (also called carcinoma in situ or
testicular intraepithelial neoplasia), or family history of testicular cancer are at risk of
developing testicular cancer. (See 'Testicular cancer' above.)
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Causes of scrotal pain in children and adolescents
Authors:
Joel S Brenner, MD, MPH
Aderonke Ojo, MD
Section Editors:
Amy B Middleman, MD, MPH, MS Ed
Gary R Fleisher, MD
Laurence S Baskin, MD, FAAP
Deputy Editor:
James F Wiley, II, MD, MPH
complete.
Literature review current through: Aug 2019. | This topic last updated: Jun 26, 2018.
INTRODUCTIONThe causes of scrotal pain will be reviewed here. The evaluation of scrotal
pain or swelling and causes of scrotal swelling are discussed separately. (See "Evaluation of
scrotal pain or swelling in children and adolescents" and "Causes of painless scrotal swelling
in children and adolescents".)
BACKGROUNDThe spectrum of conditions that affect the scrotum and its contents ranges
from incidental findings to pathologic events that require expeditious diagnosis and treatment
(eg, testicular torsion, testicular cancer). The most common causes of acute scrotal pain in
children and adolescents include testicular torsion, torsion of the appendix testis, and
epididymitis. In one review of 238 consecutive boys, ages 0 to 19 years, who presented with
acute scrotal pain to a children's hospital over a two-year period, 16 percent had testicular
torsion, 46 percent had torsion of the appendix testis, and 35 percent had epididymitis [1].
TESTICULAR TORSIONTesticular torsion is the most dramatic and potentially serious of

the acute processes affecting the scrotal contents because it may result in the loss of the
testicle. Normal testicular anatomy is depicted in the figure (figure 1).
Intravaginal torsion results from inadequate fixation of the testis to the tunica vaginalis
through the gubernaculum testis. The most common abnormality associated with testicular
torsion is known as the "bell clapper" deformity: The testicle lacks the normal attachment to
the tunica vaginalis (permitting increased mobility) and rests transverse within the scrotum
(figure 2) [2]. The bell clapper deformity may be bilateral and predisposes to testicular
torsion.
If fixation of the lower pole of the testis to the tunica vaginalis is insufficiently broad-based
or absent, the testis may torse (twist) on the spermatic cord (figure 3). The twisting of the
spermatic cord within the tunica vaginalis causes venous compression and subsequent edema
of the testicle and cord with ultimate ischemia of the testicle caused by arterial occlusion
[2,3].
Neonatal testicular torsion, which is extravaginal, is discussed separately. (See "Neonatal

testicular torsion".)
Testicular torsion has two peak incidences: a small one in the neonatal period and a large one
during puberty, but it can occur at any age. The incidence is estimated to be 1 in 4000 in
males younger than 25 years old [4]. Approximately 65 percent of cases occur in boys
between the ages of 12 and 18 years [5,6]. The increased incidence during adolescence is
thought to be secondary to the increasing weight of the testes during pubertal development
[7].
Clinical presentation — Patients classically present with an abrupt onset of severe testicular
or scrotal pain, usually of less than 12 hours' duration [2,8,9]; however, inguinal or lower
abdominal pain may be the presenting complaint [10]. Nearly 90 percent of patients may
have associated nausea and vomiting [11,12]. The pain can be isolated to the scrotum or may
radiate to the lower abdomen [5,7]. The pain is constant unless the testicle is torsing and
detorsing. A typical presentation, particularly in children, is for the patient to awaken with
scrotal pain in the middle of the night or in the morning. Many boys report a previous episode
of pain [2,5,7,13]. However, one study reported only 8 percent of the patients with torsion
had a history of pain in the past [8].
On physical examination, the scrotum may be edematous, indurated and erythematous and
the affected testis usually is tender, swollen, and slightly elevated because of shortening of
the cord from twisting (picture 1). The testis may be lying horizontally, displacing the
epididymis from its normal posterolateral position. A reactive hydrocele may also be present.
The cremasteric reflex (elevation of the testis in response to stroking of the upper inner thigh)
is absent in nearly all cases of torsion, but it also may be absent in boys without torsion,
particularly if they are younger than six months [8,9,14-17].
Prehn reported that elevation of the scrotal contents relieves the pain in patients with
epididymitis and aggravates or has no effect on the pain in patients with testicular torsion [5].
However, Prehn sign is not a reliable distinguishing feature between torsion and other
diagnoses in children [13,18].
Intermittent torsion — Intermittent testicular torsion, characterized by the sudden onset of

acute and intermittent sharp testicular pain and scrotal swelling, with rapid resolution (within
seconds to a few minutes) and long intervals without symptoms, should be considered in all
boys with a history of such scrotal pain and/or swelling without other identifiable causes
[19,20].
In one review of 50 patients with intermittent testicular torsion, 26 percent reported nausea or
vomiting, and 21 percent reported that the pain awakened them from sleep [20]. Physical
findings of intermittent testicular torsion may include horizontal or very mobile testes,
anterior epididymis, or bulkiness of the spermatic cord from partial twisting [19,20]. These
findings are usually present to varying degrees on physical examination. However, the
clinical and radiographic evaluations of some boys with intermittent torsion may be normal,
highlighting the importance of immediate follow-up for recurrent or worsening pain.
All boys suspected to have intermittent testicular torsion should have an ultrasound that
includes imaging of the spermatic cord. Although the testes may have normal architecture
and flow, in some cases views of the cord show a whirlpool sign or a pseudomass. Boys with
intermittent complaints, normal physical examination, and an unremarkable ultrasound of the
testis spermatic cord at the time of presentation should have a follow-up evaluation within
seven days unless pain recurs sooner. Ultrasound for intermittent torsion is at best 75 percent
sensitive, and the diagnosis of this condition remains clinical [21].
Diagnosis — The diagnosis of testicular torsion can be made clinically. Thus, when clinical
findings indicate a high likelihood for testicular torsion (eg, acute onset of severe testicular
pain in association with nausea or vomiting, absent cremasteric reflex, and testicular changes
on physical examination (picture 1)), the clinician should promptly consult a surgeon with
pediatric urologic expertise to evaluate the patient and make a decision regarding operative
exploration and repair.
Observational studies suggest that clinical findings can reliably identify testicular torsion. For
example, in a retrospective study of 79 boys with an acute scrotum (10 percent with testicular
torsion), the absence of ipsilateral cremasteric reflex, skin changes, and the presence of
nausea and or vomiting were most consistently predictive of torsion based upon adjusted
analysis of 22 factors [22].
In a prospective study of 338 children with an acute scrotum evaluated at a single institution,
the following clinical scoring system for testicular torsion was derived [23]:
●Nausea or vomiting – 1 point
●Testicular swelling – 2 points
●Hard testis on palpation – 2 points
●High riding testis – 1 point
●Absent cremasteric reflex – 1 point
A score ≥5 diagnosed testicular torsion with a sensitivity of 76 percent, specificity of 100

percent, and a positive predictive value of 100 percent (prevalence 15 percent). A score ≤2
excluded testicular torsion with a sensitivity of 100 percent, a specificity of 82 percent, and a
negative predictive value of 100 percent. A retrospective validation of this score in 116
children seen for acute scrotum at a different institution found similar results.
Taken together, these studies support the practice of early surgical consultation for children in
whom testicular torsion is strongly suspected based upon history and physical examination
rather than performing imaging. Although the scoring system described above had a high
negative predictive value for testicular torsion, further validation is needed before it is
routinely used to exclude testicular torsion without a confirmatory ultrasound.
Role of imaging — A color Doppler ultrasound of the scrotum is typically undertaken in

patients with equivocal clinical findings when the performance of imaging will not
significantly delay treatment. Demonstration of decreased testicular perfusion or twisting of
the spermatic cord is consistent with testicular torsion [24]. Decreased testicular perfusion
also can be seen in some patients with a large hydrocele, abscess, hematoma, or scrotal hernia
[12]. Negative scans (ie, normal or increased testicular flow) may occur rarely [9,19], usually
with spontaneous detorsion and partial or intermittent torsion [19].
The Doppler ultrasound can discern testicular and epididymal size, scrotal fluid, scrotal wall
thickening, enlarged appendix testis, twisting of the spermatic cord, and arterial flow in the
testis and epididymis. The reported sensitivity and specificity of Doppler ultrasound in the
detection of testicular torsion range from 69 to 100 percent and 77 to 100 percent,
respectively [8,25-30]. The usefulness of Doppler ultrasound is limited in small prepubertal
testes with lower blood flow.
The nuclear scan measures testicular perfusion. The reported sensitivity and specificity of
scintigraphy are 100 percent and 97 percent, respectively [26,30]. However, a nuclear scan
takes several hours to perform and is typically not available quickly enough to permit timely
operative detorsion and orchiopexy.
Management — The diagnosis of testicular torsion, whether made clinically or

radiographically, requires immediate consultation with a urologist (table 1).
The treatment for a torsed testicle that remains viable involves surgical detorsion and fixation
(orchiopexy) of both testes. Orchiectomy is performed if the testicle is nonviable. The
viability of a torsed testicle is dependent upon the duration and completeness of torsion.
Typical rates of viability according to duration of torsion have been described as follows
[5,7,13]:
●Detorsion within 4 to 6 hours – 100 percent viability
●Detorsion after 12 hours – 20 percent viability
●Detorsion after 24 hours – 0 percent viability
Surgery never should be delayed on the assumption of nonviability based upon a clinical
estimate of duration of torsion. Some patients with a prolonged period of symptoms may
have had intermittent torsion or a partial torsion and testicles that are salvageable.
The contralateral hemiscrotum typically is explored during surgery because the bell clapper
deformity usually is bilateral. Exploration permits fixation of the contralateral testis to
prevent future torsion [2,5,13,31].
Some authors report decreased fertility after unilateral testicular torsion when the testis is left
in situ [32-35], possibly because of immune-mediated damage to the contralateral testis
[34,36,37]. However, no evidence of decreased fertility or anti-sperm antibodies was found in
one study of prepubertal boys with testicular torsion [38], and the fertility issue remains
controversial.
Manual detorsion — We suggest that children and adolescents with testicular torsion based
upon clinical findings or documented on ultrasound undergo an attempt at manual detorsion
prior to surgery if emergency operative care is not rapidly available (figure 4). Manual
detorsion of the torsed testicle can restore blood flow while the patient awaits surgical
correction and increases the probability of testicular salvage [12,39-41]. As an example, in an
observational study of 133 patients (median age 16 years) with testicular torsion, successful
manual detorsion (72 patients) was associated with a testicular salvage rate of 97 percent
compared with 75 percent salvage in patients in whom detorsion was not attempted or was
not successful [41]. Delay in presentation and surgical wait time did not differ significantly
between the groups although median time to surgery was greater than three hours in both
groups.
The procedure is best performed after appropriate sedation and analgesia have been
administered [12,42] (see "Procedural sedation in children outside of the operating room"):
●Grasp the testicle and rotate it within the scrotum outward towards the thigh (medial to
lateral) one or two full 360 degree turns (figure 4).
●Prompt relief of pain lower position of the testis in the scrotum, and return of arterial flow
on Doppler ultrasound suggests detorsion [12]. If Doppler ultrasound is not rapidly available,
then a Doppler stethoscope can also be used to detect the return of arterial pulsations in the
affected testis.
●If there is no relief or pain worsens, try rotating the testicle in the opposite direction (lateral
to medial).
●Prepare the patient for surgical exploration and orchiopexy; prompt urologic consultation
should occur for all patients.
The classic teaching is that the testis usually rotates medially and is detorsed by rotating it
outward toward the thigh. However, in a retrospective analysis of 200 consecutive boys aged
18 months to 20 years who underwent surgical exploration for testicular torsion, lateral
rotation was present in one-third of cases [43].
Surgical exploration is necessary even after clinically successful manual detorsion because
partial torsion is frequently present and orchiopexy must be performed to prevent an
additional episode [41,43].
Neonatal testicular torsion — Neonatal testicular torsion is discussed separately. (See

"Neonatal testicular torsion".)
TORSION OF THE APPENDIX TESTIS OR APPENDIX EPIDIDYMISThe appendix testis

is a small vestigial structure on the anterosuperior aspect of the testis (an embryologic
remnant of the Müllerian duct system) (figure 5). It measures about 0.3 cm. The appendix
epididymis is a vestigial remnant of the Wolffian duct that is located at the head of the
epididymis. The pedunculated shape of these appendages predisposes them to torsion, which
can produce scrotal pain that ranges from mild to severe. Torsion of the appendix testis or
appendix epididymis (figure 5) occurs most commonly in boys between 7 and 12 years of age
[44].
Clinical presentation — The pain of torsion of the appendix testis or appendix epididymis is
of sudden onset, like the pain of testicular torsion.
Physical examination of boys with torsion of the appendix testis or epididymis typically
demonstrates a nontender testicle and a tender localized mass that is palpable, usually at the
superior or inferior pole [45]. The appendix may be gangrenous or black and appears through
the scrotum as the "blue dot sign" (picture 2).
A normal cremasteric reflex may be present, and a reactive hydrocele may be palpated. Blood
flow to the affected testis is normal or increased and can be demonstrated on Doppler
ultrasound or nuclear scan [2,45].
Diagnosis — The diagnosis of torsion of the appendix testis or appendix epididymis can be
made clinically, as described above. Doppler ultrasound or nuclear scan may be helpful in
cases where testicular torsion cannot otherwise be excluded.
Testicular ultrasound will show the torsed appendage as a lesion of low echogenicity with a
central hypoechogenic area [46]. Color Doppler reveals normal blood flow to the testis with
an occasional increase on the affected side, possibly due to inflammation. Doppler may be
less accurate in a prepubertal patient because of lower baseline testicular perfusion.
Radionuclide imaging denotes a "hot dot" sign at the torsed appendage. However, this finding
is unreliable if the symptoms are less than five hours old and will be seen in only 45 percent
of patients whose symptoms have lasted 5 to 24 hours [47].
Management — The management of a torsed appendix testis or appendix epididymis is

supportive, with analgesics, bed rest, and scrotal support to help alleviate swelling (table 1).
The pain should resolve in 5 to 10 days. Surgery (removal of the testicular appendix) is
reserved for patients who have persistent pain; the contralateral hemiscrotum need not be
explored [5,13,48].
EPIDIDYMITISInflammation of the epididymis is known as epididymitis (figure 6).

Epididymitis occurs more frequently among late adolescents but also occurs in younger boys
who deny sexual activity [7,8,13]. Several factors may predispose postpubertal boys to
develop subacute epididymitis, including sexual activity, heavy physical exertion, and direct
trauma (eg, bicycle or motorcycle riding). Bacterial epididymitis in prepubertal boys is
associated with structural anomalies of the urinary tract [49-51].
Among sexually active males, chlamydia is the most common microbial agent, followed by
N. gonorrhea, E. coli, and viruses. Organisms that less commonly cause epididymitis include
Ureaplasma, Mycobacterium, and cytomegalovirus, or cryptococcus in patients with HIV
infection.
Infectious epididymitis in prepubertal boys and adolescents who are not sexually active may
be caused by Mycoplasma pneumoniae, enteroviruses, or adenoviruses [52]. Bacterial
infection appears to be uncommon in such patients. As an example, an observational study of
97 cases of epididymitis who had urine cultures found that only 4 percent had a bacterial
infection and, in patients with positive urine cultures, the organisms isolated frequently were
not sensitive to commonly prescribed empiric antibiotics [53].
Clinical presentation — Patients with epididymitis may present with acute or subacute onset
of pain and swelling isolated to the epididymis [51]. A history of frequency, dysuria, urethral
discharge, and/or fever may be present [2,8,12,45]. On physical examination, the affected
testis has a normal vertical lie; the scrotum may be red and parchment-like (although this is
an uncommon finding); scrotal edema is present in at least 50 percent of cases [8,10,11].
Sometimes an inflammatory nodule is felt with an otherwise soft, nontender epididymis.
In contrast to patients with testicular torsion, patients with epididymitis usually have a normal
cremasteric reflex (if they have one under normal conditions) [2,8]. Patients with
epididymitis may experience pain relief with elevation of the testis (Prehn sign), but this is
not a reliable marker for epididymitis [5,13,54].
When epididymitis is suspected, the patient should provide a urinalysis and urine culture.
Evaluation for sexually transmitted infections in adolescent patients who have findings
consistent with sexually transmitted epididymitis is also appropriate. As in the adult male,
options include rapid molecular testing, nucleic acid amplification testing of urethral
discharge and/or nucleic acid amplification testing of urine, Gram stain of urethral discharge
(if present), and/or culture. (See "Evaluation of acute scrotal pain in adults", section on
'Clinical features and diagnosis'.)
Patients with epididymitis may have leukocytosis and pyuria; however, urinalysis may be
normal. Urine culture often is negative. In one retrospective study of patients with acute
scrotal pathology, only 15 percent of those with epididymitis had a positive urinalysis (>10
white blood cells per high-power field) [8]. Earlier studies reported positive urinalysis in 24
to 59 percent of patients with epididymitis [50,55].
Diagnosis — The diagnosis of epididymitis can be made clinically as described above.

However, if the diagnosis is uncertain, Doppler ultrasonography or nuclear scan may be
helpful, revealing increased blood flow to the affected epididymis [45,46,56].
A urinalysis and urine culture should be obtained in all patients with epididymitis. In
addition, the United States Centers for Disease Control (CDC) recommend that providers
obtain the following studies in patients who have findings consistent with sexually
transmitted epididymitis [57]:
●Gram-stained smear and culture of urethral exudates or intraurethral swab specimen, or
●Nucleic acid amplification tests for N. gonorrhea and C. trachomatis, and
●Urine culture and first void urine for leukocytes
●Syphilis and HIV testing
Management — Treatment varies according to the severity of the case at presentation and
suspected etiology (table 1). Treatment for sexually transmitted epididymitis includes
antibiotics [57], analgesics, scrotal support, elevation, and bed rest in the acute phase [57]. It
is equally important to assure that the sexual partner gets treatment if a sexually transmitted
disease is suspected as the etiology. The diagnosis and treatment regimen should be
reevaluated if there is no improvement after three days of therapy [57].
●The first-line treatment regimen recommended by the CDC when the most likely cause is
chlamydia or gonorrhea includes ceftriaxone (250 mg IM in one dose) plus doxycycline (100
mg orally twice a day for seven days) or azithromycin (1 g orally once) [57,58]. Quinolones
are no longer recommended for the treatment of epididymitis if N. gonorrhoeae is suspected
because of increasing resistance of N. gonorrhoeae to these agents.
●For acute epididymitis most likely caused by enteric organisms or with negative gonococcal
culture or nucleic acid amplification test, ofloxacin (300 mg PO twice a day for 10 days) or
levofloxacin (500 mg PO once daily for 10 days) may be used [58].
The treatment of epididymitis in prepubertal boys depends upon whether they have an
associated urinary tract infection. Those who have pyuria, positive urine cultures, or
underlying risk factors for urinary tract infection should be treated empirically with
antibiotics that cover coliforms and achieve adequate levels in epididymal tissues (eg,
trimethoprim-sulfamethoxazole, cephalexin) [12]. Additional evaluation of boys with urinary
tract infection is discussed separately. (See "Urinary tract infections in infants older than one
month and young children: Acute management, imaging, and prognosis", section on
'Imaging'.)
The treatment of nonbacterial epididymitis is supportive and includes scrotal support, rest,
NSAIDs, and possibly antibiotics [59].
OTHER CAUSES
Trauma — It is not uncommon for boys and men to suffer minor episodes of scrotal trauma;
only rarely does a severe testicular injury result, usually because of compression of the testis
against the pubic bones from a direct blow or straddle injury. The spectrum of injuries can
range from a hematocele (hematoma in the tunica vaginalis) to an intratesticular hematoma to
disruption of the tunica albuginea causing testicular rupture. Color Doppler ultrasonography
can accurately diagnose the extent of injury. Testicular rupture requires surgical repair.
Lesser injuries are managed according to the clinical severity and often can be treated
nonoperatively. (See "Scrotal trauma in children and adolescents".)
Incarcerated inguinal hernia — Herniation of bowel or omentum into the scrotum can present
with pain and a scrotal mass (picture 3). Bowel sounds may be audible in the scrotum. (See
"Inguinal hernia in children".)
Immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP]) — IgAV (HSP) is a

systemic vasculitis syndrome characterized by nonthrombocytopenic purpura, arthralgia,
renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. In one
review of 93 boys with IgAV (HSP), 22 had scrotal involvement [60]. The onset of scrotal
pain may be acute or insidious. In boys who lack other characteristic findings of IgAV (HSP),
sonography can usually distinguish IgAV (HSP) from testicular torsion. Treatment of IgAV
(HSP) is supportive. (See "IgA vasculitis (Henoch-Schönlein purpura): Management".)
Orchitis — Viral (mumps, rubella, coxsackie, echovirus, lymphocytic choriomeningitis virus,

parvovirus) and bacterial (brucellosis) infections can cause orchitis in children and
adolescents [61]. Clinical manifestations may include scrotal swelling, pain, and tenderness
with erythema and shininess of the overlying skin, although the presentation may be more
severe. (See appropriate topic reviews.)
Patients with orchitis are treated symptomatically with bed rest, nonsteroidal
antiinflammatory agents, support of the inflamed testis, and ice packs. (See "Mumps", section
on 'Treatment'.)
Referred pain — Boys who have the acute onset of scrotal pain without local inflammatory
signs or a mass on examination may be suffering from referred pain to the scrotum. The
precise incidence of referred pain is unclear. The conditions that may cause referred scrotal
pain are diverse, reflecting the anatomy of the three somatic nerves that travel to the scrotum:
the genitofemoral, ilioinguinal, and posterior scrotal nerves [62]. Retrocecal appendicitis is an
important (albeit uncommon) cause of referred scrotal pain in children and adolescents [63].
Reported causes of referred pain in adults include abdominal aortic aneurysm, urolithiasis,
lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal
tumor, and postherniorrhaphy pain [62]. (See "Acute appendicitis in children: Clinical
manifestations and diagnosis".)
Nonspecific scrotal pain — Sometimes older boys and young teenagers present with
complaints of mild scrotal pain and a completely normal physical examination. These
characteristics make testicular torsion and other pathologic conditions highly unlikely.
Imaging of such patients is not usually necessary. They should be instructed to return for
immediate evaluation if the pain increases in severity or is associated with testicular swelling.

●Basics topic (see "Patient education: Epididymitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●The clinical presentations, diagnosis, and management of the most common causes of
testicular or scrotal pain in children and adolescents are described above (table 2 and table 1).
●The differential diagnosis of acute scrotal pain primarily includes testicular torsion, torsion
of the appendix testis, and epididymitis.
●Testicular torsion generally presents with the abrupt onset of severe pain associated with
nausea or vomiting. The testicle may lie transversely in the scrotum and be retracted; the
cremasteric reflex is typically absent. Testicular torsion is an emergency; timely diagnosis
and treatment are vital for survival of the testis. The diagnosis of testicular torsion, whether
made clinically or radiographically, requires immediate consultation with a urologist (table
1). (See 'Diagnosis' above.)
●We suggest that children and adolescents with testicular torsion based upon clinical findings
or ultrasound undergo an attempt at manual detorsion prior to surgery if emergency operative
care is not rapidly available (Grade 2C). (See 'Manual detorsion' above.)
●The treatment for a torsed testicle that remains viable involves surgical detorsion and
fixation (orchiopexy) of both testes. Orchiectomy is performed if the testicle is nonviable.
(See 'Management' above.)
●A color Doppler ultrasound of the scrotum is typically undertaken in patients with equivocal
clinical findings when the performance of imaging will not significantly delay treatment.
●Torsion of the appendix testis also presents with the abrupt onset of pain, but the pain
typically is less severe than in testicular torsion. Pain is localized to the region of the
appendix testis (anterosuperior), and a "blue dot" sign may be apparent at the same location
(picture 2). Treatment may be symptomatic, or the appendix testis may be surgically excised.
(See 'Torsion of the appendix testis or appendix epididymis' above.)
●Patients with epididymitis may present with acute or subacute onset of pain and swelling
isolated to the epididymis. A history of frequency, dysuria, urethral discharge, and/or fever
may be present. The affected testis has a normal vertical lie; scrotal edema often is present.
Treatment depends on the severity of illness and the suspected etiology. (See 'Epididymitis'
above.)
●Other causes of scrotal pain in children and adolescents include scrotal trauma, an
incarcerated inguinal hernia, immunoglobulin A vasculitis (Henoch-Schönlein purpura),
orchitis, and, less commonly, referred pain from a retrocecal appendicitis. (See 'Other causes'
above.)
https://www.uptodate.com/contents/causes-of-scrotal-pain-in-children-and-adolescents/abstract/1
Evaluation of acute scrotal pain in adults
Author:
Robert C Eyre, MD
Section Editor:
Michael P O'Leary, MD, MPH
Deputy Editor:
Jane Givens, MD
complete.
Literature review current through: Aug 2019. | This topic last updated: Sep 17, 2019.
INTRODUCTIONThe spectrum of conditions affecting the scrotum and its contents ranges
from acute pathologic events that require immediate surgical intervention to incidental
findings that simply require patient reassurance.
This topic addresses the clinical evaluation and management of the acute scrotum, which is
defined as moderate to severe scrotal pain that develops over the course of minutes to one to
two days, in adults. Nonacute scrotal conditions in adults and scrotal disorders in children and
adolescents are discussed separately. (See "Evaluation of nonacute scrotal conditions in
adults" and "Evaluation of scrotal pain or swelling in children and adolescents".)
NORMAL ANATOMYThe testis, tunica vaginalis, epididymis, spermatic cord, appendix

testis, and appendix epididymis are anatomic structures that may be involved in nonacute
scrotal conditions (figure 1):
●The testis (testicle) is the male gonad responsible for production of sperm and androgens
(primarily testosterone). The normal testis is ovoid, about 3 to 5 cm in length, and firm with
smooth surfaces. One testis may be slightly larger than the other, and one testis (usually the
left) may hang slightly lower.
●The tunica vaginalis is a fascial layer which encapsulates a potential space that encompasses
the anterior two-thirds of the testis. Different types of fluid may accumulate within the tunica
vaginalis (eg, water with a hydrocele, blood with a hematocele, pus with a pyocele).
●The epididymis is a tightly coiled tubular structure located on the posterior aspect of the
testis running from its superior to inferior poles. Sperm travels from the tubules of the rete
testis into the epididymis, which joins the vas deferens distally. The function of the
epididymis is to aid in the storage and transport of sperm cells that are produced in the testes,
as well as to facilitate sperm maturation.
●The spermatic cord, which consists of the testicular blood vessels and the vas deferens, is
connected to the base of the epididymis and traverses into the retropubic space.
●The appendix testis is a small vestigial structure on the anterosuperior aspect of the testis,
representing an embryologic remnant of the Müllerian duct system (figure 2). It measures
approximately 0.3 cm in length and is predisposed to torsion (twisting), particularly during
childhood, because of its pedunculated shape. The appendix epididymis is a Wolffian duct
vestigial structure found on the top of the epididymis.
PATIENT EVALUATION
Conditions requiring emergent treatment — The first priority in the evaluation of the acute
scrotum is to identify conditions that require urgent medical or surgical intervention, namely
testicular torsion, acute epididymitis (or epididymo-orchitis), and Fournier’s gangrene. These
diagnoses are all associated with diffuse scrotal pain.
Delayed diagnosis and treatment of acute epididymitis is associated with increased morbidity.
Delayed surgical intervention of testicular torsion can lead to loss of the testis, infertility, and
other complications.
Testicular torsion and acute epididymitis are the most common causes of acute scrotal pain in
adults. Although much less common, Fournier's gangrene (necrotizing fasciitis of the
perineum), which can cause acute scrotal swelling, is a surgical emergency. (See 'Acute
epididymitis or epididymo-orchitis' below and 'Testicular torsion' below and 'Fournier’s
gangrene' below.)
Initial evaluation — The initial evaluation of acute scrotal pain includes a directed history
and physical examination including vital signs.
Patients should be asked about the nature and timing of the onset of pain, its location, and the
presence of fever and lower urinary tract symptoms (eg, frequency, urgency, dysuria).
Patients should be asked about any prior history of inguinal or scrotal surgery.
The abdomen, inguinal region, and scrotal skin and contents should be carefully examined
(figure 1). The normal testis is ovoid, about 3 to 5 cm in length, and firm with smooth
surfaces. One testis may be slightly larger than the other, and one testis (usually the left) may
hang slightly lower. The epididymis, which is a spongy, tube-shaped structure, is palpable
along the posterior aspect of each testis.
The cremasteric reflex (lightly stroking the superior and medial part of the thigh to make the
cremaster muscle contract and pull up the ipsilateral testis) should be assessed. A negative
cremasteric reflex is associated with testicular torsion.
Examination for an inguinal hernia is best performed with the patient standing. The inguinal
areas should be inspected for bulges, and a provocative maneuver (eg, cough) may be
necessary to expose the hernia. If a hernia is not apparent on inspection, the maneuver should
be repeated as the clinician invaginates the scrotum. (See "Classification, clinical features,
and diagnosis of inguinal and femoral hernias in adults", section on 'Diagnosis'.)
The location and characteristics of scrotal symptoms and physical examination findings can
inform the probable cause, as outlined below (table 1). For example, the onset of testicular
torsion may be acute and severe, while epididymitis typically has a more gradual onset.
Diagnostic considerations
Diffuse scrotal pain — The main diagnostic considerations for diffuse scrotal pain include
testicular torsion, acute epididymo-orchitis, and Fournier’s gangrene.
In patients with fever, tachycardia, or hypotension, Fournier’s gangrene should be

considered. Typical symptoms include diffuse scrotal, groin, and lower abdominal pain,
tenderness, and swelling (picture 1). Other clinical signs may include tense edema outside the
involved skin, blisters/bullae, crepitus, and subcutaneous gas. This diagnosis necessitates
urgent surgical evaluation. (See 'Fournier’s gangrene' below.)
If Fournier’s gangrene is not suspected, testing the cremasteric reflex may be helpful in
determining the most likely cause of diffuse scrotal pain [1].
●If the cremasteric reflex is negative (the testis does not pull up when the ipsilateral thigh is
stroked), a presumptive diagnosis of testicular torsion should be suspected. The cremasteric
reflex is most often seen in boys between 30 months and 12 years of age, and it is less
consistent in older males; thus, no singular test should be used to establish a diagnosis of
torsion. Other supportive findings include a high-riding testis, bell clapper deformity (figure
3), and profound testicular swelling. If clinical features are classic, the diagnosis can be made
on these findings alone. However, if the findings are less clear, scrotal ultrasound should be
performed to confirm the diagnosis. All patients with suspected or confirmed testicular
torsion should be referred urgently for urologic evaluation. (See 'Testicular torsion' below.)
●If the cremasteric reflex is positive (the testis pulls up when the ipsilateral thigh is stroked),
acute epididymo-orchitis or orchitis is a more likely diagnosis.
•In acute epididymo-orchitis, there is pain, swelling, and tenderness of the testis with some
localization posteriorly. Epididymal swelling and pain typically precede secondary
inflammatory changes in the testis. Fever and lower urinary tract symptoms may be present.
Urinalysis, urine culture, and urine studies for Neisseria gonorrhoeae and Chlamydia
trachomatis should be obtained in this setting. For patients with suspected acute epididymo-
orchitis, antibiotic therapy should be given empirically while awaiting test results. (See
'Acute epididymitis or epididymo-orchitis' below.)
•Acute orchitis from mumps is characterized by diffuse testicular swelling and tenderness and
may be difficult to distinguish from acute epididymo-orchitis. Supportive findings for mumps
would include a local outbreak and the presence of constitutional symptoms and parotitis.
Suspicion of mumps should prompt serologic testing. (See 'Other etiologies' below.)
Localized scrotal pain — For patients with localized scrotal pain and tenderness, the location
can suggest potential causes.
●If symptoms are localized to the posterior aspect of the testis, a presumptive diagnosis of
acute epididymitis can be made. Lower urinary tract symptoms may be present. Urinalysis,
urine culture, and urine studies for N. gonorrhoeae and C. trachomatis should be obtained in
this setting. For patients with suspected acute epididymitis, antibiotic therapy should be given
empirically while awaiting test results. (See 'Acute epididymitis or epididymo-orchitis'
below.)
●If symptoms are localized to the anterior superior pole of the testis, testicular appendiceal
torsion is likely. Another supportive finding is the blue dot sign (picture 2), which occurs in a
minority of patients. (See 'Other etiologies' below.)
Additional evaluation — When the cause of scrotal pain is not evident after the initial
evaluation, or symptoms do not improve with empiric treatment, other causes of scrotal pain
should be considered. These include trauma, post-vasectomy pain, testicular cancer,
immunoglobulin A (IgA) vasculitis (Henoch-Schönlein purpura), acute idiopathic scrotal
edema, and referred pain (diagnosis of exclusion). In these settings, a scrotal ultrasound and
urology referral for consultation are advised. (See 'Other etiologies' below.)
ACUTE EPIDIDYMITIS OR EPIDIDYMO-ORCHITISAcute epididymitis is the most

common cause of scrotal pain in adults in the outpatient setting, accounting for 600,000 cases
per year in the United States [2]. More advanced cases may present with testicular pain,
swelling, and tenderness (epididymo-orchitis). As the evaluation and management of acute
epididymo-orchitis is similar to that of acute epididymitis [3], we will refer only to acute
epididymitis in this section.
Etiology — Acute epididymitis is most commonly infectious in etiology but can also be from
noninfectious causes such as trauma and autoimmune diseases [4]. Noninfectious causes
generally present as subacute or chronic epididymitis and are discussed elsewhere. (See
"Evaluation of nonacute scrotal conditions in adults", section on 'Chronic epididymitis'.)
N. gonorrhoeae and C. trachomatis are the most common organisms responsible for acute
epididymitis in men under the age of 35 [4-7]. (See "Clinical manifestations and diagnosis of
Neisseria gonorrhoeae infection in adults and adolescents" and "Clinical manifestations and
diagnosis of Chlamydia trachomatis infections", section on 'Clinical syndromes in men'.)
Escherichia coli, other coliforms, and Pseudomonas species are more frequent in older men,
often in association with obstructive uropathy from benign prostatic hyperplasia. Men of any
age who engage in insertive anal intercourse are also at increased risk for acute bacterial
epididymitis from exposure to coliform bacteria in the rectum. Other less common organisms
responsible for acute epididymitis include Ureaplasma species, Mycoplasma genitalium (see
"Mycoplasma genitalium infection in men and women"), Mycobacterium tuberculosis, and
Brucella species.
Clinical features and diagnosis — The clinical features of acute epididymitis include
localized testicular pain with tenderness and swelling on palpation of the affected epididymis,
which is located posteriorly on the testis (figure 1). More advanced cases present with
secondary testicular pain and swelling (epididymo-orchitis). Scrotal wall erythema and a
reactive hydrocele may be present. A positive Prehn sign (manual elevation of the scrotum
relieves pain) is more often seen with epididymitis than testicular torsion. The cremasteric
reflex is positive.
In rare cases, acute epididymitis can cause serious illness. It is characterized by severe pain
and swelling of the surrounding structures, often accompanied by fever, rigors, and lower
urinary tract symptoms (frequency, urgency, and dysuria). It may be seen in conjunction with
acute prostatitis (epididymo-prostatitis), particularly in older men who may have underlying
prostatic obstruction or have undergone recent urologic instrumentation or catheterization.
The diagnosis of acute epididymitis is made presumptively based on history and physical
examination after ruling out other causes requiring urgent surgical intervention (see
'Conditions requiring emergent treatment' above). In all suspected cases, a urinalysis, urine
culture, and a urine nucleic acid amplification test (NAAT) for N. gonorrhoeae and C.
trachomatis should be performed, although urinalysis and urine culture are often negative in
patients without lower urinary tract symptoms [8]. Identification of a pathogen on urine or
urethral swab testing supports the presumptive diagnosis.
With the exception of mumps, isolated orchitis without epididymitis is very uncommon in
adults and so epididymo-orchitis should be the primary diagnosis to consider when an adult
appears to have orchitis. However, in non-immune adults, mumps and other “childhood”
viruses can rarely cause orchitis. (See "Causes of scrotal pain in children and adolescents",
section on 'Orchitis' and 'Other etiologies' below.)
Management — Management of acute epididymitis varies according to its severity [2]. Most
cases can be treated on an outpatient basis with oral antibiotics, nonsteroidal
antiinflammatory drugs (NSAIDs), local application of ice, and scrotal elevation. Acutely ill
patients may warrant hospitalization for parenteral antibiotics and intravenous hydration.
Empiric antimicrobial treatment should be given pending NAAT and culture results based on
the most likely pathogens as follows:
●Patients under the age of 35 or who are at risk of sexually transmitted infections (eg, sex
outside of monogamous relationship) – We suggest coverage for N. gonorrhoeae and C.
trachomatis with ceftriaxone (250 mg intramuscular injection in one dose) plus doxycycline
(100 mg orally twice a day for 10 days). For patients unable to tolerate doxycycline,
azithromycin (1 g orally in one dose) is an alternative option. Fluoroquinolones are not
recommended for the treatment of acute epididymitis if gonorrhea is suspected because of the
widespread resistance of N. gonorrhoeae to these drugs. (See "Treatment of uncomplicated
Neisseria gonorrhoeae infections", section on 'Fluoroquinolones'.)
●Patients 35 years of age or older and who are at low risk for sexually transmitted
infections – We suggest coverage for enteric pathogens with levofloxacin 500 mg orally once
daily for 10 days. For patients who are unable to take fluoroquinolones, trimethoprim-
sulfamethoxazole (one double-strength tablet twice a day for 10 days) is a good alternative.
●Patients of any age who practice insertive anal intercourse – We suggest coverage for N.
gonorrhoeae, C. trachomatis, and enteric pathogen infections with ceftriaxone (250 mg
intramuscular injection in one dose) plus a fluoroquinolone (levofloxacin 500 mg orally once
daily for 10 days).
These treatment regimens are in accordance with the US Centers for Disease Control and
Prevention (CDC) guidelines [7]. Studies defining the optimal antimicrobial regimens for
acute epididymitis are limited, and the selection of drugs is based on treatment evidence for
other types of infections with these pathogens. In general, doxycycline is preferred over
azithromycin for the management of chlamydial epididymitis because of the lack of studies
on the latter drug for this infection. (See "Treatment of uncomplicated Neisseria gonorrhoeae
infections" and "Treatment of Chlamydia trachomatis infection".)
Patients with acute epididymitis should generally improve within 48 to 72 hours after starting
appropriate antibiotic therapy. If the symptoms are not better, other causes of scrotal pain
should be considered. Scrotal ultrasound and referral to a urologist for consultation are
advised.
Patients who are diagnosed with N. gonorrhoeae or C. trachomatis epididymitis should be

retested in several months because of the high rate of reinfection and should be instructed to
refer their sexual partners for evaluation and treatment. (See "Treatment of uncomplicated
Neisseria gonorrhoeae infections", section on 'Management of sexual partners' and
"Treatment of Chlamydia trachomatis infection", section on 'Management of sex partners'.)
TESTICULAR TORSION
Epidemiology — Testicular torsion is a urologic emergency that is more common in neonates

and postpubertal boys than adults, although it can occur at any age [9]. In one retrospective
review, 17 of 44 cases (39 percent) of testicular torsion in hospitalized patients were in men
ages 21 and older [10]. The prevalence of testicular torsion in adult patients hospitalized with
acute scrotal pain is 25 to 50 percent [9,11-14]. Testicular torsion in children is discussed
separately. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular
torsion'.)
Pathophysiology — Testicular torsion results from inadequate fixation of the lower pole of
the testis to the tunica vaginalis (figure 1). If fixation is absent or insufficiently broad-based,
the testis may torse (twist) on the spermatic cord, potentially producing ischemia from
reduced arterial inflow and venous outflow obstruction (figure 4). Testicular torsion may
occur after an inciting event (eg, trauma, vigorous physical activity) or spontaneously.
It is generally believed that the testis suffers irreversible damage after eight hours of ischemia
from testicular torsion [8,15]. Infertility may result, even with a normal contralateral testis.
This may be due to disruption of the immunologic "blood-testis" barrier, and exposure of
antigens from germ cells and sperm to the general circulation, with subsequent development
of anti-sperm antibodies [16]. However, a more likely cause is loss of overall germ cell
volume [17].
Clinical features and diagnosis — The clinical features of testicular torsion include the acute
onset of moderate to severe testicular pain with profound diffuse tenderness and swelling and
a negative cremasteric reflex on physical examination.
Symptoms often occur several hours after vigorous physical activity or minor trauma to the
testicles [18]. Nausea and vomiting as well as diffuse lower abdominal pain may be
associated. Patients may present initially with lower abdominal pain, nausea, and vomiting
without localization of pain to the scrotum. Thus, all patients with these symptoms should
have a thorough scrotal examination. Another common presentation, particularly in children,
is awakening with scrotal pain in the middle of the night or in the morning, likely related to
cremasteric contraction with nocturnal sexual stimulation during the rapid eye movement
sleep cycle. The patient should be asked about prior similar episodes that might suggest
intermittent testicular torsion.
The classic finding is an asymmetrically high-riding testis with its long axis oriented
transversely instead of longitudinally related to shortening of the spermatic cord from the
torsion (“bell clapper deformity”) (figure 3). Profound testicular swelling occurs early, while
a reactive hydrocele and overlying erythema of the scrotal wall may be evident 12 to 24 hours
after the onset of symptoms. In the early stages, an experienced examiner can often
differentiate the swollen, exquisitely tender testis from the softer, less tender epididymis
posteriorly. The finding of a tender mass (“knot”) superior to the testis makes the diagnosis of
torsion extraordinarily likely. It is often possible to detorse a testis during examination by
gentle rotation away from the midline. Relief of pain with detorsion indicates likely testicular
torsion. (See 'Manual detorsion' below.)
The cremasteric reflex should be assessed, and is usually absent in patients with testicular
torsion (table 1). This finding helps distinguish testicular torsion from acute epididymitis or
epididymo-orchitis and other causes of scrotal pain in which the reflex is generally intact [1].
The cremasteric reflex is assessed by stroking or gently pinching the skin of the upper thigh
while observing the ipsilateral testis. A normal response is cremasteric contraction with
elevation of the testis (see 'Diffuse scrotal pain' above). The cremasteric reflex is most often
seen in boys between 30 months and 12 years of age, and it is less consistent in older males;
thus, no singular test should be used to establish a diagnosis of torsion.
Patients clinically suspected of having testicular torsion should be immediately referred to a

urologist or emergency department for evaluation.
Ultrasound — Many cases of testicular torsion do not require imaging to confirm the
diagnosis if the history and physical examination are pathognomonic. However, in equivocal
cases, color Doppler ultrasonography should be urgently obtained. It is important to request
that the ultrasonographer perform a thorough evaluation of the spermatic cord up to the level
of the internal ring, and not just limit the examination to the scrotum. However, if access to
scrotal ultrasonography is unavailable or if the ultrasound cannot exclude testicular torsion,
surgical exploration is advised [19].
It is also important to note that scrotal ultrasounds may occasionally show present but
diminished blood flow to the testis and epididymis or even increased blood flow to the
epididymis as the result of reperfusion if a testis has either spontaneously or manually
detorsed. Therefore, the importance of a careful history and physical examination as well as a
clear understanding of the possible limitations in interpreting imaging studies cannot be
overstated.
In a study of 56 patients who underwent surgical exploration for acute scrotal pain and had an
ultrasound performed preoperatively [11], none of the 22 patients with testicular torsion at
surgical exploration had a detectable Doppler signal over the affected side (sensitivity 100
percent). By contrast, normal testicular blood flow and cord-compression tests were
demonstrated clearly in 33 of 34 patients who did not have testicular torsion (specificity 97
percent). In another report, ultrasonography had a sensitivity and specificity of 82 and 100
percent, respectively, for the diagnosis of testicular torsion [20]. Subsequent studies
confirmed the high sensitivity and specificity of ultrasound in the diagnosis of testicular
torsion, although results may vary based on ultrasound technique [21,22].
Utilization of high-resolution ultrasonography has further increased the sensitivity and

specificity of diagnosing testicular torsion. In this technique, the twisting of the spermatic
cord is directly visualized as an inhomogeneous mass at the inguinal or paratesticular position
(the “Whirlpool Sign”) [23,24]. In a study of 919 patients (mean age 9 years; range 1 day to
19 years), traditional color Doppler ultrasonography of the scrotum had a sensitivity of 76
percent, while high-resolution ultrasonography of the spermatic cord for linear or twist
configuration reached 96 and 99 percent sensitivity and specificity, respectively [25].
Management — Treatment for suspected testicular torsion is urgent surgical exploration with
intraoperative detorsion and fixation of the testes. Delay in detorsion of a few hours may lead
to progressively higher rates of testicular nonviability. Manual detorsion should be performed
if surgical intervention is not immediately available.
Surgery — Detorsion and fixation of both the involved testis and the contralateral uninvolved
testis should be performed since inadequate gubernacular fixation is usually a bilateral defect.
Extended periods of ischemia (>8 hours) may cause infarction of the testis with necrosis
requiring orchiectomy. Further testicular ischemic injury may occur even after detorsion due
to a “testicular compartment syndrome.” This occurs when reperfusion and parenchymal
edema in the space confined by the inelastic tunica albuginea cause increased pressure, which
may reduce parenchymal blood flow. In a case report of three patients, all of whom had
ischemia for at least six hours, an incision in the tunica albuginea and placement of a tunica
vaginalis patch after reduction of the torsion resulted in salvage of the testis in all patients
with preservation of size and symmetrical growth at one-year follow-up [26].
The outcome of surgery may be worse in adults than in children. In one retrospective study,
the testicular salvage rates of patients age <21 years and age ≥21 years were 70 and 41
percent, respectively [10]. While the time to presentation was the most important factor
affecting the salvage rate, adult men also had a greater degree of cord twisting than the
younger group, which may partly explain the difference in outcomes.
Color Doppler ultrasonography has been used to predict the outcome of testicular salvage. In
one study, the paired findings of no blood flow to the testis and heterogeneous echotexture of
the testicular parenchyma were 100 percent predictive of testicular loss at exploration [27].
However, one should be very cautious about delaying urgent surgery even in the presence of
these findings if there is any clinical judgment that that testis may still be salvageable.
Manual detorsion — If surgery is not available within two hours, an attempt to detorse the
testicle manually is warranted (figure 5). Observational studies in children have suggested
relief of pain and improved testicular salvage with manual detorsion (see "Causes of scrotal
pain in children and adolescents", section on 'Manual detorsion'). In general, analgesics are
not given because of concern of masking continued torsion. Surgical exploration is necessary
even after successful manual detorsion because orchiopexy (securing the testicle to the scrotal
wall) should be performed to prevent recurrence, and residual torsion may be present that can
be further relieved [28].
The classic teaching is that the testis usually rotates medially during torsion and can be
detorsed by rotating it outward toward the thigh. However, in a retrospective analysis of 200
consecutive males age 18 months to 20 years who underwent surgical exploration for
testicular torsion, lateral rotation was present in one-third of cases [28]. The degree of
twisting of the testis may range from 180 to 720 degrees, requiring multiple rounds of
detorsion.
Successful detorsion is suggested by [29]:

●Relief of pain
●Conversion of the transverse lie of the testis to a longitudinal orientation
●Lower position of the testis in the scrotum
●Return of normal arterial pulsations on color Doppler ultrasound
FOURNIER’S GANGRENEFournier's gangrene is a necrotizing fasciitis (mixed

aerobic/anaerobic infection) of the perineum which often involves the scrotum (see
"Necrotizing soft tissue infections"). It is typically seen in patients who are diabetic, have had
longstanding indwelling urethral catheters, have had urethral trauma in the presence of
urinary infection, or are immunocompromised.
It is characterized by severe pain that generally starts on the anterior abdominal wall and
migrates into the gluteal muscles, scrotum, and penis (picture 1). Clinical features may
include tense edema outside the involved skin, blisters/bullae, crepitus, and subcutaneous gas,
as well as systemic findings such as fever, tachycardia, and hypotension. Computed
tomography (CT) and magnetic resonance imaging (MRI) may show air along the fascial
planes or deeper tissue involvement. However, imaging studies should not delay surgical
exploration when there is clinical evidence of progressive soft tissue infection. (See
"Necrotizing soft tissue infections", section on 'Clinical manifestations'.)
Treatment of necrotizing fasciitis consists of early aggressive surgical exploration with

debridement of necrotic tissue, broad spectrum antibiotic therapy, and hemodynamic support
as needed [30]. Patients with Fournier's gangrene may ultimately require cystostomy,
colostomy, or orchiectomy. (See "Necrotizing soft tissue infections", section on 'Treatment'.)
OTHER ETIOLOGIES
●Torsion of the appendix testis – Torsion of the appendix testis rarely occurs in adults [31].
Most cases are in children between the ages of 7 and 14 years, with a mean age of 10.6 years
[32]. (See "Causes of scrotal pain in children and adolescents", section on 'Torsion of the
appendix testis or appendix epididymis'.)
The onset of testicular pain from torsion of the appendix testis is generally more gradual than
with testicular torsion and may range from mild to severe. On physical examination, a
reactive hydrocele is often present that may transilluminate, and tenderness is localized to the
appendix testis on the anterosuperior testis. Careful inspection of the scrotal wall may detect
the classic "blue dot" sign (picture 2), which is caused by infarction and necrosis of the
appendix testis but seen in a minority of patients [33,34].
If the diagnosis is unclear on physical examination, a scrotal ultrasound can be performed

that will show the torsed appendage as a lesion of low echogenicity with a central
hypoechogenic area [35]. Color Doppler imaging reveals normal blood flow to the testis with
an occasional increase on the affected side, possibly related to inflammation.
Management of acute torsion of the appendix testis consists of the local application of ice and
nonsteroidal antiinflammatory drugs (NSAIDs). Recovery is gradual, with some discomfort
often lasting for weeks to months. Surgical excision of the appendix testis is reserved for
patients who have persistent pain in spite of these measures.
●Trauma – It is common for men to suffer minor scrotal trauma with daily activities.
However, only rarely does it result in severe testicular injury, usually from compression of
the testis against the pubic bones from a direct blow or straddle injury. The spectrum of
traumatic complications can range from a hematocele (blood within the tunica vaginalis) to a
pyocele (pus within the tunica vaginalis) to testicular rupture. Color Doppler ultrasonography
can accurately diagnose the extent of any injury. Testicular rupture requires surgical repair.
Uncomplicated injuries are managed conservatively. Young men who engage in sports where
blunt scrotal injury risk is high (eg, hockey, lacrosse) should wear appropriate protection.
●Post-vasectomy pain – Patients who have had a vasectomy may have firmness in the entire
epididymis secondary to ductal obstruction. Some men will develop a painful nodule at the
site of division of the vas deferens on the testicular side. The nodule is a sperm granuloma
that forms because of leakage of sperm from the lumen of the vas deferens, creating an
immunologic response to the "foreign" protein, which was previously sequestered from
immune surveillance by the blood-testis barrier. Management consist of NSAIDs, local
application of ice (10 to 15 minutes a few times/day) for one to two days, and warm baths (20
minutes daily) thereafter. Rarely, patients who have intractable pain may require surgical
excision of the granuloma.
●Inguinal hernia – Herniation of bowel or omentum through the spermatic cord into the
scrotum can present with pain and a scrotal mass. Examination for an inguinal hernia is best
performed with the patient standing. The inguinal areas should be inspected for bulges, and a
provocative maneuver (eg, cough) may be necessary to expose the hernia. If a hernia is not
apparent on inspection, the cough should be repeated as the clinician invaginates the scrotum.
A strangulated hernia may be associated with severe pain (picture 3). Pain with inguinal
hernias is most likely to be localized in the groin or abdomen rather than the scrotum. Bowel
sounds may be audible in the scrotum. Groin ultrasound or CT scan may be helpful if the
clinical diagnosis is uncertain. Management of inguinal hernias is discussed separately. (See
"Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and
"Overview of treatment for inguinal and femoral hernia in adults".)
●Mumps orchitis – Mumps is an acute self-limited viral syndrome characterized by malaise,

headache, myalgias, anorexia, and parotid swelling. Epididymo-orchitis is the most common
complication of mumps in the adult male, with most patients having fever and parotitis
preceding the onset of orchitis. There is often severe testicular pain and tenderness, with
swelling and erythema of the scrotum (picture 4); bilateral involvement is present in up to 30
percent of cases. Diagnosis is suspected clinically but can be confirmed serologically.
Patients with mumps orchitis are managed symptomatically with the local application of ice,
scrotal elevation, and NSAIDs. (See "Mumps", section on 'Orchitis or oophoritis'.)
●Testicular cancer – While most testicular tumors present as painless nodules, rapidly
growing germ cell tumors may cause acute scrotal pain secondary to hemorrhage and
infarction. A mass is generally palpable, and scrotal ultrasound should be performed to
confirm the diagnosis. (See "Clinical manifestations, diagnosis, and staging of testicular germ
cell tumors", section on 'Clinical manifestations'.)
●Immunoglobulin A vasculitis (Henoch-Schönlein purpura) – Immunoglobulin A (IgA)
vasculitis is a systemic vasculitis characterized by nonthrombocytopenic purpura, arthralgia,
renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. Scrotal
pain can be the presenting symptom, and its onset may be acute or insidious. The diagnosis is
often suspected clinically, but scrotal ultrasound may need to be performed to distinguish IgA
vasculitis from testicular torsion. It generally shows marked edema of the scrotal skin and
contents with intact vascular flow in the testes. Management of scrotal pain is symptomatic.
(See "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis" and
"IgA vasculitis (Henoch-Schönlein purpura): Management".)
●Acute idiopathic scrotal edema – Some men develop significant scrotal or penile edema of
unknown etiology, usually without pain [36,37]. The condition has been more often reported
in children [37]. It should be differentiated from anasarca (generalized edema), in which
excess extracellular fluid can collect in the loose scrotal sac. (See "Clinical manifestations
and evaluation of edema in adults".)
In men with acute idiopathic scrotal edema, ultrasonography should be performed to assess
for testicular abnormalities. It typically shows thickening of the subcutaneous scrotal tissue
without other lesions or masses [36]. Management consists of scrotal elevation, and the
condition generally resolves within 48 hours [36].
●Referred pain – Men who have the acute onset of scrotal pain without tenderness, swelling,
or other findings on physical examination may have referred pain to the scrotum. The
conditions that cause referred pain are diverse, reflecting the anatomy of the somatic nerves
(genitofemoral, ilioinguinal, and posterior scrotal) that travel to the scrotum [38]. They
include abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root
impingement, retrocecal appendicitis, retroperitoneal tumor, and post-herniorrhaphy state.

●Basics topics (see "Patient education: Epididymitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●The acute scrotum is defined as moderate to severe scrotal pain that develops over the
course of minutes to one to two days. (See 'Introduction' above.)
●The most common causes of acute scrotal pain in adults are acute epididymitis and
testicular torsion. Other conditions that may be responsible include Fournier's gangrene
(necrotizing fasciitis of the perineum), torsion of the appendix testis, trauma, post-vasectomy
pain, inguinal hernia, mumps orchitis, testicular cancer, immunoglobulin A (IgA) vasculitis
(Henoch-Schönlein purpura), referred pain, and acute idiopathic scrotal edema. (See 'Acute
epididymitis or epididymo-orchitis' above and 'Testicular torsion' above and 'Fournier’s
gangrene' above and 'Other etiologies' above.)
●The first priority in the evaluation of the acute scrotum is to identify any condition that
requires urgent medical or surgical intervention. Delayed diagnosis and treatment of acute
epididymitis is associated with increased morbidity. Delayed surgical intervention of
testicular torsion can lead to loss of the testis, infertility, and other complications. Although
much less common, Fournier's gangrene (necrotizing fasciitis of the perineum), which can
cause acute scrotal swelling, is a surgical emergency. (See 'Conditions requiring emergent
treatment' above.)
●The initial evaluation of acute scrotal pain includes a directed history and physical
examination. Patients should be asked about the nature and timing of the onset of pain, its
location, and the presence of lower urinary tract symptoms (eg, frequency, urgency, dysuria)
and constitutional symptoms (eg, fever, chills). The abdomen, inguinal region, and scrotal
skin and contents should be carefully examined (figure 1). A urinalysis and urine culture, as
well as diagnostic studies for Neisseria gonorrhoeae and Chlamydia trachomatis should be
obtained if the diagnosis of acute epididymitis is being considered or if lower urinary tract
symptoms are present. A diagnostic approach based upon characteristic clinical features can
be used for evaluation of the acute scrotum (table 1). (See 'Initial evaluation' above.)
●The clinical features of acute epididymitis include localized testicular pain with tenderness
and swelling on palpation of the affected epididymis, which is located posteriorly on the
testis (figure 1). The diagnosis is made presumptively based on history and physical
examination after ruling out other causes requiring urgent intervention. Identification of a
pathogen on urine or urethral swab testing supports the presumptive diagnosis. (See 'Acute
epididymitis or epididymo-orchitis' above.)
●Empiric antimicrobial treatment for acute epididymitis should be given pending nucleic acid
amplification test (NAAT) and culture results based on the most likely pathogens as follows
(see 'Management' above):
•In patients under the age of 35 or who are at risk of sexually transmitted infections, we
suggest coverage for N. gonorrhoeae and C. trachomatis (Grade 2C). Ceftriaxone (250 mg
intramuscular injection in one dose) plus doxycycline (100 mg orally twice a day for 10
days) is an acceptable regimen. Azithromycin (1 g orally in one dose) is an alternative option
in patients unable to tolerate doxycycline. Fluoroquinolones are not recommended for the
treatment of acute epididymitis if gonorrhea is suspected because of the widespread
resistance of N. gonorrhoeae to these drugs.
•In patients 35 years of age or older who are at low risk for sexually transmitted infections,
we suggest coverage for enteric pathogens (Grade 2C). Levofloxacin 500 mg orally once
daily for 10 days is an acceptable regimen. For patients who are unable to take
fluoroquinolones, trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for
10 days) is a good alternative.
•In patients of any age who practice insertive anal intercourse, we suggest coverage for N.
gonorrhoeae, C. trachomatis, and enteric pathogen infections (Grade 2C). Ceftriaxone (250
mg intramuscular injection in one dose) plus levofloxacin 500 mg orally once daily for 10
days is an acceptable regimen.
●The clinical features of testicular torsion include the acute onset of moderate to severe
testicular pain with profound diffuse tenderness and swelling and a negative cremasteric
reflex on physical examination. Doppler ultrasound of the scrotum is a useful adjunct in
equivocal cases but should not delay surgical exploration. Urgent surgical exploration is the
standard of care for testicular torsion. For patients who cannot be taken to surgery within two
hours, an attempt at manual detorsion is warranted (figure 5). Surgical exploration is
necessary even after successful manual detorsion because orchiopexy (securing the testicle to
the scrotal wall) must be performed to prevent recurrence, and residual torsion may be
present that can be further relieved. (See 'Testicular torsion' above.)
●Fournier's gangrene is a necrotizing fasciitis (mixed aerobic/anaerobic infection) of the

perineum which often involves the scrotum. It is characterized by severe pain that generally
starts on the anterior abdominal wall and migrates into the gluteal muscles, scrotum, and
penis (picture 1). Clinical features may include tense edema outside the involved skin,
blisters/bullae, crepitus, and subcutaneous gas, as well as systemic findings such as fever,
tachycardia, and hypotension. Management of necrotizing fasciitis consists of early
aggressive surgical debridement, broad spectrum antibiotic therapy, and hemodynamic
support as needed. (See "Necrotizing soft tissue infections" and 'Fournier’s gangrene' above.)
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Scrotal Swelling

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ection Editors:

Amy B Middleman, MD, MPH, MS Ed

INTRODUCTIONThe clinical presentation, diagnosis, and management of hydrocele,

Communicating hydroceles usually develop as a result of failure of the processus vaginalis to

Hydroceles are common in newborns (whether related to delayed closure of a patent

In older children and adolescents, noncommunicating hydroceles may be idiopathic or may

Diagnosis — The diagnosis of hydrocele can be made by physical examination and

Management — Surgical repair is indicated for communicating hydroceles that persist

Idiopathic noncommunicating hydroceles are often asymptomatic. Surgical repair may be

VARICOCELEA varicocele is a collection of dilated and tortuous veins in the pampiniform

Clinical presentation and diagnosis — Patients with varicoceles can be asymptomatic or

●Abdominal mass (eg, retroperitoneal tumors, kidney tumors, or lymphadenopathy) [13]

Management — There are no clear guidelines established for treatment of a varicocele in

●To alleviate symptoms such as pain, heaviness, or swelling.

●When obtained, abnormal seminal fluid analysis.

SPERMATOCELE (EPIDIDYMAL CYST)A spermatocele (epididymal cyst) is a painless,

TESTICULAR CANCERTesticular cancer accounts for 20 percent of cancer diagnosed in

Clinical presentation — Testicular cancer usually presents as a painless mass discovered by

Management — The treatment of testicular cancer is discussed separately. (See "Overview of

●Nephrotic syndrome – The nephrotic syndrome is characterized by nephrotic range

●Other conditions producing generalized edema due to hypoproteinemia or increased

INFORMATION FOR PATIENTSUpToDate offers two types of patient education materials,

●A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus

●Boys with a history of cryptorchidism, previous testicular cancer, HIV infection,

Use of UpToDate is subject to the Subscription and License Agreement.

TESTICULAR TORSIONTesticular torsion is the most dramatic and potentially serious of

Neonatal testicular torsion, which is extravaginal, is discussed separately. (See "Neonatal

Intermittent torsion — Intermittent testicular torsion, characterized by the sudden onset of

●Nausea or vomiting – 1 point

●Testicular swelling – 2 points

●Hard testis on palpation – 2 points

●High riding testis – 1 point

●Absent cremasteric reflex – 1 point

A score ≥5 diagnosed testicular torsion with a sensitivity of 76 percent, specificity of 100

Role of imaging — A color Doppler ultrasound of the scrotum is typically undertaken in

Management — The diagnosis of testicular torsion, whether made clinically or

●Detorsion within 4 to 6 hours – 100 percent viability

●Detorsion after 12 hours – 20 percent viability

●Detorsion after 24 hours – 0 percent viability

Neonatal testicular torsion — Neonatal testicular torsion is discussed separately. (See

TORSION OF THE APPENDIX TESTIS OR APPENDIX EPIDIDYMISThe appendix testis

Management — The management of a torsed appendix testis or appendix epididymis is

EPIDIDYMITISInflammation of the epididymis is known as epididymitis (figure 6).

Diagnosis — The diagnosis of epididymitis can be made clinically as described above.

●Gram-stained smear and culture of urethral exudates or intraurethral swab specimen, or

●Nucleic acid amplification tests for N. gonorrhea and C. trachomatis, and

●Urine culture and first void urine for leukocytes

●Syphilis and HIV testing

Immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP]) — IgAV (HSP) is a

Orchitis — Viral (mumps, rubella, coxsackie, echovirus, lymphocytic choriomeningitis virus,

INFORMATION FOR PATIENTSUpToDate offers two types of patient education materials,

●Basics topic (see "Patient education: Epididymitis (The Basics)")

SUMMARY AND RECOMMENDATIONS

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NORMAL ANATOMYThe testis, tunica vaginalis, epididymis, spermatic cord, appendix

In patients with fever, tachycardia, or hypotension, Fournier’s gangrene should be

ACUTE EPIDIDYMITIS OR EPIDIDYMO-ORCHITISAcute epididymitis is the most

Patients who are diagnosed with N. gonorrhoeae or C. trachomatis epididymitis should be

Epidemiology — Testicular torsion is a urologic emergency that is more common in neonates

Patients clinically suspected of having testicular torsion should be immediately referred to a

Utilization of high-resolution ultrasonography has further increased the sensitivity and

Successful detorsion is suggested by [29]: