Testicle Pain: Causes, Symptoms & When to Seek Emergency Care

What Are the Common Causes of Testicle Pain?

Testicle pain can be caused by testicular torsion (twisted testicle), epididymitis (infection of the epididymis), orchitis (testicular inflammation), trauma, hydrocele (fluid accumulation), varicocele (enlarged veins), or inguinal hernia. Sudden severe pain is most concerning for torsion, while gradual-onset pain with fever suggests infection.

The scrotum contains the testicles (testes), which are the male reproductive glands responsible for producing sperm and testosterone. Each testicle is connected to the body by the spermatic cord, which contains blood vessels, nerves, and the vas deferens (the tube that carries sperm). The epididymis is a coiled tube at the back of each testicle that stores and transports sperm.

Understanding the anatomy of the scrotum helps explain why different conditions cause different types of pain. Problems affecting the blood supply to the testicle, such as torsion, cause sudden, severe pain because the tissue is being deprived of oxygen. Infections, on the other hand, typically cause gradual-onset pain as inflammation develops over time.

The causes of testicular and scrotal pain vary significantly by age group. In newborns and infants, the most common concerns are undescended testicles and congenital hydrocele. Adolescents and young adults are at highest risk for testicular torsion, while sexually active adults are more likely to develop epididymitis from sexually transmitted infections. Older men often experience epididymitis related to urinary tract infections or prostate problems.

Testicular Torsion

Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This is a urological emergency because the testicle can die within hours without blood flow. Torsion is most common during puberty (ages 12-18) but can occur at any age, including in newborns. It affects approximately 1 in 4,000 males under 25 years old.

The condition typically occurs spontaneously, often during sleep, physical activity, or after minor trauma. Some individuals have an anatomical predisposition called the "bell clapper deformity," where the testicle hangs more freely within the scrotum and is more likely to twist. When torsion occurs, the twisted cord strangles the blood vessels, causing immediate and severe pain.

Epididymitis

Epididymitis is inflammation of the epididymis, usually caused by bacterial infection. In sexually active men under 35, it is most commonly caused by sexually transmitted bacteria such as chlamydia or gonorrhea. In older men and children, it is typically caused by urinary tract bacteria, often related to urinary tract infections or prostate problems.

The infection usually spreads from the urethra or bladder through the vas deferens to the epididymis. Without treatment, the infection can spread to the testicle itself, causing epididymo-orchitis. While painful and uncomfortable, epididymitis is treatable with antibiotics and generally does not require emergency surgery.

Orchitis

Orchitis is inflammation of the testicle itself, which can be caused by viral or bacterial infections. The most well-known cause is mumps, which can lead to orchitis in about 20-30% of post-pubertal males who contract the disease. Vaccination against mumps has significantly reduced this risk. Bacterial orchitis usually occurs as a complication of epididymitis when the infection spreads to the testicle.

Other Causes

Several other conditions can cause scrotal pain or swelling. Hydrocele is a collection of fluid around the testicle that causes painless swelling - it is common in newborns and often resolves on its own. Varicocele is enlargement of the veins within the scrotum, similar to varicose veins, which can cause a dull ache. Inguinal hernia occurs when abdominal contents protrude through the inguinal canal into the scrotum, causing swelling and sometimes pain. Trauma to the scrotum can cause bruising, swelling, and pain of varying severity.

What Are the Symptoms of Testicular and Scrotal Conditions?

Symptoms vary by condition: testicular torsion causes sudden, severe pain with nausea and a high-riding testicle; epididymitis causes gradual pain with fever and urinary symptoms; hydrocele causes painless swelling; and undescended testicle presents as an absent testicle in the scrotum. The pattern of symptom onset is key to diagnosis.

Recognizing the different symptom patterns associated with various scrotal conditions is essential for determining the urgency of medical care needed. The speed of onset, associated symptoms, and physical characteristics all provide important diagnostic clues. Understanding these differences can literally mean the difference between saving and losing a testicle in cases of torsion.

Pain characteristics vary significantly between conditions. Torsion pain is typically described as sudden, severe, and constant - patients often describe it as the worst pain they have ever experienced. In contrast, infectious causes like epididymitis usually begin with mild discomfort that gradually worsens over days. Some conditions, like hydrocele, cause no pain at all, only swelling.

Symptoms of Testicular Torsion

Testicular torsion presents with distinctive symptoms that should prompt immediate medical attention. The hallmark symptom is sudden, severe pain in one testicle that comes on within minutes. The pain is typically constant and does not improve with rest or position changes. Many patients also experience nausea and vomiting due to the severity of the pain.

Physical examination findings in torsion are characteristic. The affected testicle often appears higher than normal in the scrotum (called a "high-riding" testicle) because the twisted cord shortens. The testicle may also lie in an unusual horizontal position rather than the normal vertical orientation. The scrotum may become red and swollen, and the testicle is extremely tender to touch. Importantly, elevating the testicle does not relieve the pain in torsion (negative Prehn's sign), unlike in epididymitis where elevation often provides some relief.

Symptoms of Epididymitis and Orchitis

Epididymitis typically begins with mild discomfort that gradually worsens over several days. Patients often notice pain at the back of the testicle initially, corresponding to the location of the epididymis. As the infection progresses, the entire scrotum may become swollen, red, and tender. Fever is common, and patients may experience urinary symptoms such as painful urination, frequent urination, or urethral discharge if the infection is sexually transmitted.

Orchitis symptoms are similar to epididymitis and often occur together. When mumps virus causes orchitis, patients typically develop testicular symptoms 4-7 days after the characteristic facial swelling (parotitis). The testicle becomes swollen and painful, and patients feel generally unwell with fever and fatigue.

When Should You See a Doctor for Testicle Pain?

Seek emergency care immediately for sudden severe testicle pain, especially with nausea or a high-riding testicle. See a doctor within 24-48 hours for gradual-onset pain with fever or urinary symptoms. Schedule a routine appointment for painless swelling or lumps. Never ignore sudden severe testicular pain - time is critical for torsion.

The decision about when and where to seek medical care for testicular symptoms depends primarily on the speed of onset and severity of symptoms. Understanding these guidelines can help you make appropriate decisions that could save a testicle in an emergency while avoiding unnecessary emergency visits for non-urgent conditions.

The most important principle is that sudden, severe testicular pain should always be treated as an emergency until proven otherwise. Even if the pain comes and goes (intermittent torsion), this still warrants immediate evaluation because the testicle may twist and untwist spontaneously, with each episode causing progressive damage.

Emergency Care (Immediately)

Go directly to an emergency department if you experience sudden, severe pain in one testicle that comes on within minutes. This is especially urgent if accompanied by nausea, vomiting, or scrotal swelling. The testicle may appear higher than normal or at an unusual angle. Pain that started suddenly and does not improve with position changes should be evaluated immediately.

Time is critical in testicular torsion. Surgery within 6 hours of symptom onset has a 90-100% success rate for saving the testicle. After 6-12 hours, the success rate drops to approximately 50%. After 24 hours, the testicle usually cannot be saved. Do not delay seeking care to "see if it gets better" - this delay can result in permanent loss of the testicle.

Urgent Care (Within 24-48 Hours)

See a doctor promptly (but not necessarily at an emergency department) if you have gradual-onset scrotal pain that has developed over days, especially if accompanied by fever, painful urination, or urethral discharge. These symptoms suggest infection (epididymitis) that requires antibiotic treatment but is not a surgical emergency.

You should also seek prompt evaluation if you notice new scrotal swelling that is tender to touch, or if you have had a recent sexually transmitted infection or urinary tract infection and develop scrotal symptoms.

Routine Appointment

Schedule a routine doctor's appointment for painless scrotal swelling that has developed gradually over weeks or months. This may indicate hydrocele, varicocele, or other non-urgent conditions. Any new lump or mass in the testicle should also be evaluated, but in the absence of pain, this can usually wait for a regular appointment within a few days to a week.

How Are Testicular and Scrotal Conditions Diagnosed?

Diagnosis begins with physical examination of the scrotum and testicles. Doppler ultrasound is the key imaging test, showing blood flow to the testicle (absent in torsion). Urine tests help identify infections. In suspected torsion, surgery may be performed based on clinical examination alone because diagnostic delay can result in testicle loss.

The diagnostic approach to scrotal conditions prioritizes rapid identification of testicular torsion, which requires immediate surgery. In many cases, the clinical history and physical examination provide enough information to proceed directly to surgery without waiting for imaging studies. This approach reflects the time-sensitive nature of torsion and the understanding that delays can result in irreversible damage.

When the diagnosis is less clear, imaging studies - particularly Doppler ultrasound - can help distinguish between conditions. However, it is important to understand that normal blood flow on ultrasound does not completely rule out torsion, and clinical suspicion should guide management decisions.

Physical Examination

The doctor will examine the scrotum and testicles by gentle palpation. In torsion, the affected testicle is typically extremely tender, may be positioned higher than normal, and may lie in a horizontal orientation. The cremasteric reflex (contraction of the scrotum when the inner thigh is stroked) is typically absent on the affected side in torsion.

In epididymitis, tenderness is usually localized to the back of the testicle initially, where the epididymis is located. The doctor may also check for urethral discharge and examine the prostate in older men. Elevation of the testicle may relieve pain in epididymitis (positive Prehn's sign) but not in torsion.

Doppler Ultrasound

Doppler ultrasound is the most useful imaging test for evaluating scrotal conditions. It uses sound waves to create images of the testicles and can measure blood flow using the Doppler effect. In testicular torsion, blood flow to the affected testicle is reduced or absent. In epididymitis, blood flow is typically increased due to inflammation.

Ultrasound can also identify other conditions such as hydrocele (appearing as fluid around the testicle), varicocele (dilated veins), tumors, or hernias. However, if torsion is strongly suspected based on clinical findings, surgery should not be delayed for imaging - the testicle can be examined directly during the procedure.

Laboratory Tests

Urine tests can help identify urinary tract infections or sexually transmitted infections that may be causing epididymitis. The doctor may collect samples to test for chlamydia and gonorrhea, especially in sexually active patients. Blood tests, including a complete blood count and inflammatory markers (CRP), can indicate infection or inflammation.

In cases where testicular cancer is suspected (typically presenting as a painless mass), blood tests for tumor markers such as alpha-fetoprotein (AFP), beta-hCG, and lactate dehydrogenase (LDH) may be ordered.

How Are Testicular and Scrotal Conditions Treated?

Treatment depends on the condition: testicular torsion requires emergency surgery (orchiopexy) to untwist and fix the testicle; epididymitis is treated with antibiotics for 2-3 weeks; viral orchitis requires supportive care; hydrocele in infants often resolves spontaneously; undescended testicle requires surgery by 18 months of age.

The treatment approach for testicular and scrotal conditions varies dramatically depending on the underlying cause. Torsion requires immediate surgical intervention, while infections can usually be managed with antibiotics. Some benign conditions, particularly in children, may resolve without treatment. Understanding the treatment options helps patients know what to expect and emphasizes the importance of accurate diagnosis.

Recovery times also vary significantly. Patients undergoing torsion surgery typically need several weeks to recover and must avoid strenuous activity. Those treated for epididymitis may feel better within days of starting antibiotics but should complete the full course of treatment to prevent recurrence or complications.

Treatment for Testicular Torsion

Testicular torsion is treated with emergency surgery called orchiopexy. The surgeon makes an incision in the scrotum, untwists the spermatic cord to restore blood flow, and assesses the viability of the testicle. If the testicle appears viable (healthy color returns after untwisting), it is stitched to the scrotal wall to prevent future torsion. The same procedure is performed on the opposite testicle because the anatomical predisposition (bell clapper deformity) is usually present on both sides.

If the testicle has been without blood flow for too long and is no longer viable, it must be removed (orchiectomy). A dead testicle left in place could become infected or trigger an immune response that damages the remaining testicle. Removal of one testicle does not typically affect fertility or hormone production, as the remaining testicle compensates.

After surgery, patients are advised to rest, apply ice to reduce swelling, and avoid strenuous activity and sexual intercourse for several weeks. Pain medication is prescribed as needed. Most patients can return to normal activities within 4-6 weeks.

Treatment for Epididymitis and Orchitis

Bacterial epididymitis is treated with antibiotics. The choice of antibiotic depends on the likely cause: in sexually active young men, treatment covers chlamydia and gonorrhea; in older men or those with urinary tract infections, antibiotics target common urinary bacteria. Treatment typically lasts 2-3 weeks. Pain relievers and anti-inflammatory medications help manage symptoms, and scrotal support (wearing supportive underwear) can provide comfort.

Viral orchitis, such as that caused by mumps, cannot be treated with antibiotics. Management focuses on supportive care: rest, pain relievers, ice application, and scrotal support. Most cases resolve within 1-2 weeks. Vaccination against mumps remains the best prevention for mumps-related orchitis.

Treatment for Hydrocele

In newborns, hydrocele often resolves spontaneously by 12-18 months of age as the communication between the abdomen and scrotum closes. In adults, hydrocele may be observed if small and asymptomatic. Larger or symptomatic hydroceles can be treated surgically (hydrocelectomy) or by aspiration with sclerotherapy, though surgical repair has lower recurrence rates.

Treatment for Undescended Testicle

Undescended testicle (cryptorchidism) is usually identified at birth or during routine pediatric examinations. In some cases, the testicle descends spontaneously during the first 6 months of life. If the testicle remains undescended after 6 months, surgery (orchiopexy) is recommended, ideally performed between 6 and 18 months of age.

During orchiopexy, the surgeon locates the undescended testicle (which may be in the inguinal canal or abdomen), brings it down into the scrotum, and stitches it in place. Early surgery is important because an undescended testicle is at increased risk for infertility and testicular cancer. Correction by 18 months of age significantly reduces these risks.

How Can You Prevent Testicular Problems?

While testicular torsion cannot be reliably prevented, you can reduce the risk of other conditions: practice safe sex to prevent STI-related epididymitis, ensure children receive mumps vaccination, wear protective gear during sports, and perform regular testicular self-examinations to detect changes early.

Prevention strategies for testicular conditions focus primarily on reducing the risk of infections and detecting problems early. While some conditions like testicular torsion occur unpredictably and cannot be prevented, others can be avoided through vaccination, safe sexual practices, and protective measures.

Regular self-examination is one of the most important things men can do for testicular health. Becoming familiar with the normal size, shape, and feel of your testicles makes it easier to notice changes that might indicate a problem. Early detection of testicular cancer, in particular, significantly improves treatment outcomes.

Protection Against Infections

Sexually transmitted infections are a leading cause of epididymitis in young men. Using condoms consistently and correctly reduces the risk of chlamydia, gonorrhea, and other STIs that can lead to epididymitis. Getting tested regularly for STIs, especially when you have new sexual partners, allows for early treatment before complications develop.

Mumps vaccination (typically given as part of the MMR vaccine) protects against mumps-related orchitis. Ensuring that children receive their recommended vaccinations and that adults have updated immunizations protects against this preventable cause of testicular inflammation.

Testicular Self-Examination

Monthly testicular self-examination helps you become familiar with your testicles so you can notice any changes. The best time to perform the exam is after a warm shower or bath when the scrotal skin is relaxed. Roll each testicle gently between your thumb and fingers, feeling for any lumps, bumps, or changes in size or consistency. The epididymis (a soft, tube-like structure at the back of each testicle) is normal and should not be confused with a lump.

It is normal for one testicle to be slightly larger than the other or to hang lower. What you are looking for are changes from your normal - any new lumps, hardening, or significant size changes. If you notice anything unusual, see a doctor for evaluation. Most testicular lumps are not cancer, but all should be checked.

Physical Protection

Wearing an athletic cup or protective supporter during contact sports, martial arts, or activities with risk of groin injury helps protect the testicles from trauma. While most testicular injuries are minor, severe trauma can cause significant damage including hematocele (blood collection in the scrotum) or even testicular rupture.

What Are the Potential Complications of Untreated Conditions?

Untreated testicular torsion results in testicle loss within hours. Delayed surgery for undescended testicle increases the risk of infertility and testicular cancer. Untreated epididymitis can lead to abscess formation, chronic pain, or infertility. Viral orchitis from mumps can occasionally cause permanent testicular damage.

Understanding the potential complications of untreated testicular conditions emphasizes the importance of timely medical care. While many complications can be avoided with prompt treatment, delays can result in permanent damage affecting fertility, hormone production, and overall health.

The testicles have two main functions: producing sperm for reproduction and producing testosterone (the primary male sex hormone). Conditions that damage or destroy testicular tissue can affect one or both of these functions. Fortunately, because there are two testicles, losing or damaging one usually does not cause significant long-term problems - the remaining testicle typically compensates.

Complications of Testicular Torsion

The primary complication of testicular torsion is loss of the testicle due to prolonged lack of blood supply. When blood flow is cut off, the testicular tissue begins to die within hours. If surgery is performed within 6 hours, there is a 90-100% chance of saving the testicle. After 6-12 hours, this drops to about 50%. After 24 hours, the testicle usually cannot be saved and must be removed.

Even with successful surgical repair, some patients experience reduced fertility or testicular atrophy (shrinkage) of the affected testicle over time. This is more likely when there was a significant delay before surgery. However, most men with one healthy testicle maintain normal fertility and hormone levels.

Complications of Undescended Testicle

An undescended testicle that is not corrected by surgery carries significant long-term risks. The most important is an increased risk of testicular cancer - men with a history of undescended testicle have a 3-10 times higher risk of developing testicular cancer, even after surgical correction. However, surgery before 18 months of age significantly reduces this risk and allows for easier monitoring.

Infertility is another major concern. The scrotum provides a cooler environment necessary for sperm production. A testicle that remains in the abdomen or inguinal canal is exposed to higher body temperatures that damage sperm production. Bilateral (both sides) undescended testicles significantly increase the risk of infertility.

Complications of Infections

Epididymitis that is not treated promptly can lead to abscess formation (a pocket of pus) that may require surgical drainage. Chronic epididymitis can develop, causing long-term pain and discomfort. In severe cases, infection can spread to the testicle (epididymo-orchitis) and may cause scarring that blocks the epididymis, potentially affecting fertility.

Mumps orchitis can occasionally cause permanent testicular damage, including testicular atrophy and reduced sperm production. Bilateral mumps orchitis (affecting both testicles) may cause infertility in some cases, though this is relatively uncommon.