Testicular Pain: Causes, Symptoms & When to Seek Emergency Care
Testicular pain is a symptom that always requires medical evaluation. The most serious cause is testicular torsion, where the testicle twists on its blood supply and requires emergency surgery within 6 hours to prevent permanent damage. Other causes include infection (epididymitis), incarcerated inguinal hernia, and trauma. If you or your child experiences sudden, severe testicular pain, seek emergency care immediately.
Quick Facts: Testicular Pain
Key Takeaways
- Testicular pain requires urgent evaluation - it can indicate testicular torsion, a surgical emergency requiring treatment within 6 hours
- Sudden, severe pain is most concerning - particularly with scrotal swelling, redness, nausea, or abnormal testicle position
- Testicular torsion is most common in adolescents (ages 12-18), but can occur at any age including newborns
- Epididymitis is more common in adults and typically causes gradual onset pain with fever and urinary symptoms
- Never delay seeking care - waiting can result in permanent testicular damage or loss
- Diagnosis typically requires physical examination and ultrasound to assess blood flow to the testicle
What Causes Testicular Pain?
Testicular pain can result from several conditions, with the most serious being testicular torsion (twisted testicle), which cuts off blood supply and requires emergency surgery. Other common causes include epididymitis (infection of the epididymis), orchitis (testicular infection), incarcerated inguinal hernia, and trauma. The cause determines the urgency of treatment.
Understanding the different causes of testicular pain is crucial because treatment approaches vary significantly. Some causes require immediate surgical intervention, while others can be managed with medication and supportive care. The key distinguishing factor is often whether pain onset is sudden or gradual, and whether other symptoms are present.
The testicles are sensitive organs with a rich nerve supply, which means pain can be intense even with minor conditions. Additionally, pain can be referred to the testicles from other areas, including the kidneys, ureters, and abdomen. This is why medical evaluation is essential to determine the true source and cause of pain.
Age plays an important role in determining the most likely cause. Adolescents are at highest risk for testicular torsion, while sexually active adults are more likely to experience epididymitis from sexually transmitted infections. Older men may develop epididymitis from urinary tract infections related to prostatic enlargement.
Testicular Torsion
Testicular torsion occurs when the testicle rotates on the spermatic cord, twisting the blood vessels that supply the testicle. This cuts off blood flow and causes sudden, severe pain. Without prompt treatment, the testicle can become permanently damaged within hours. Testicular torsion is a urological emergency.
The condition is most common during puberty, affecting approximately 1 in 4,000 males under age 25. However, it can occur at any age, including in newborns. Some individuals have an anatomical variation called "bell-clapper deformity" where the testicle is not properly anchored within the scrotum, increasing the risk of torsion. Torsion often occurs during sleep or physical activity.
Torsion of the Testicular Appendage
A small tissue appendage attached to the testicle can also twist, causing pain similar to testicular torsion but less severe. This condition is most common in boys before puberty and typically resolves on its own within several days. While not dangerous, it still requires medical evaluation to rule out true testicular torsion.
Epididymitis
Epididymitis is inflammation of the epididymis, a coiled tube located on top of each testicle that stores and carries sperm. The inflammation is usually caused by bacterial infection. In sexually active men under 35, the most common causes are sexually transmitted infections like chlamydia and gonorrhea. In older men, urinary tract infections are more often responsible.
Unlike testicular torsion, epididymitis typically develops gradually over hours to days. The pain may be accompanied by fever, urinary symptoms (burning, frequency, urgency), and discharge from the penis. The affected side of the scrotum is swollen and tender, particularly in the area of the epididymis at the top of the testicle.
Orchitis (Testicular Infection)
Orchitis is infection and inflammation of the testicle itself, rather than the epididymis. It can occur when an epididymal infection spreads to the testicle, or it may result from viral infections such as mumps. Mumps orchitis typically occurs several days after the onset of parotitis (swollen salivary glands) and can affect fertility if bilateral.
Incarcerated Inguinal Hernia
An inguinal hernia occurs when abdominal contents (usually intestine) protrude through a weakness in the abdominal wall in the groin area. When the hernia becomes trapped and cannot be pushed back in (incarcerated), it can cause severe pain in the groin and scrotum. If the blood supply to the trapped tissue is compromised (strangulated hernia), emergency surgery is required.
Symptoms of incarcerated hernia include severe pain in the abdomen, groin, or scrotum; a visible bulge that is tender and cannot be pushed back; nausea and vomiting; and redness of the groin or scrotum. In children, symptoms may also include fussiness, poor feeding, and lethargy.
Seek emergency care immediately if you experience sudden, severe testicular pain, especially with nausea, vomiting, scrotal swelling or redness, or if the testicle appears higher than normal. These may indicate testicular torsion, which requires surgery within 6 hours to save the testicle.
What Are the Symptoms of Testicular Torsion?
Testicular torsion typically presents with sudden onset of severe testicular pain, scrotal swelling and redness, nausea and vomiting, and an abnormally positioned testicle (often higher or rotated). The pain may begin during physical activity or wake someone from sleep. Unlike epididymitis, there is usually no fever or urinary symptoms.
Recognizing the symptoms of testicular torsion is critical because time is the most important factor in saving the testicle. The classic presentation is a young male who awakens with sudden, severe testicular pain. The pain is typically constant and severe, though some patients report intermittent pain if the testicle twists and untwists (intermittent torsion).
Physical examination findings that suggest torsion include a testicle that rides higher than normal in the scrotum, absence of the cremasteric reflex (normally the testicle rises when the inner thigh is stroked), and a testicle that lies in a horizontal rather than vertical orientation. The affected testicle is extremely tender to touch.
Some patients experience abdominal pain as well as testicular pain, which can lead to misdiagnosis. Nausea and vomiting are common with torsion but rare with epididymitis. Importantly, torsion does not typically cause fever or urinary symptoms, which helps distinguish it from infection.
Symptoms of Testicular Torsion
- Sudden, severe testicular pain: Often awakens the patient from sleep or occurs during physical activity
- Scrotal swelling: The affected side becomes progressively swollen
- Scrotal redness: The skin may become red and warm
- Nausea and vomiting: Common with torsion, helps distinguish from infection
- Abnormal testicle position: May appear higher, horizontal, or rotated
- Absence of cremasteric reflex: The testicle doesn't rise when inner thigh is stroked
Symptoms of Epididymitis
In contrast to torsion, epididymitis typically develops gradually over hours to days. The following symptoms suggest epididymitis rather than torsion:
- Gradual onset of pain: Develops over hours to days rather than suddenly
- Fever: Common with infection
- Urinary symptoms: Burning, frequency, urgency, or discharge
- Tenderness localized to epididymis: Initially at top of testicle before spreading
- Prehn's sign: Pain may improve when scrotum is elevated (though not reliable)
Symptoms in Children
Children with testicular torsion may not be able to clearly describe their symptoms. Parents should be alert to sudden onset of crying or irritability, refusal to walk normally, abdominal pain, vomiting, and scrotal swelling or redness. Boys may be embarrassed to report testicular symptoms, so direct questioning may be necessary if a child presents with unexplained abdominal pain or vomiting.
When Should You See a Doctor for Testicular Pain?
Any sudden, severe testicular pain should be evaluated immediately at an emergency room, as it may indicate testicular torsion requiring surgery within 6 hours. Do not wait for a doctor's appointment or to see if pain improves. Even gradual-onset testicular pain warrants same-day medical evaluation to determine the cause and appropriate treatment.
The most important message regarding testicular pain is that sudden, severe pain is a medical emergency until proven otherwise. The consequences of delaying treatment for testicular torsion are severe and irreversible - the testicle can become non-viable within hours. Even if the pain seems to improve, evaluation is still necessary because intermittent torsion can occur.
Many men are reluctant to seek care for testicular problems due to embarrassment or hoping symptoms will resolve on their own. This natural tendency can have devastating consequences when torsion is present. Emergency physicians and urologists evaluate testicular emergencies regularly and prioritize rapid assessment and treatment.
Time is critical in testicular torsion. Studies show that the testicular salvage rate is 90-100% if surgery occurs within 6 hours of symptom onset, drops to approximately 50% at 12 hours, and falls below 10% after 24 hours. Every hour of delay reduces the chance of saving the testicle.
- Pain is sudden and severe
- The scrotum is swollen or red
- You have nausea or vomiting with testicular pain
- The testicle appears higher than normal or in an abnormal position
- Pain persists for more than one hour
- You have had previous testicular torsion
What to Expect at the Emergency Room
When you arrive at the emergency room with testicular pain, the medical team will prioritize your evaluation because of the time-sensitive nature of testicular torsion. You will be asked about when the pain started, whether onset was sudden or gradual, previous episodes, and other symptoms like fever or urinary problems.
Physical examination will assess the position, size, and tenderness of the testicles, as well as check for the cremasteric reflex. In most cases, Doppler ultrasound will be performed to assess blood flow to the testicles. If torsion is strongly suspected based on clinical findings, surgery may proceed without waiting for ultrasound.
How Is Testicular Pain Diagnosed?
Diagnosis of testicular pain involves clinical history, physical examination, and usually Doppler ultrasound to evaluate blood flow to the testicle. The key question is whether testicular torsion is present, which requires emergency surgery. If clinical suspicion for torsion is high, surgery may proceed without imaging to avoid delays.
The diagnostic approach to testicular pain focuses first on excluding testicular torsion, the most time-critical diagnosis. The history and physical examination provide crucial clues: sudden onset, severe pain, nausea, and abnormal testicular position suggest torsion, while gradual onset, fever, and urinary symptoms suggest epididymitis.
However, there is significant overlap in presentations, and even experienced clinicians cannot always distinguish torsion from other causes based on examination alone. This is why imaging, typically Doppler ultrasound, plays an important role in most cases. The ultrasound can visualize blood flow to the testicle and help identify the cause of symptoms.
Physical Examination Findings
The physical examination provides important diagnostic information. Key findings evaluated include the position and lie of the testicle (horizontal vs. vertical), the cremasteric reflex (whether the testicle rises when the inner thigh is stroked), the location of maximum tenderness, and whether elevating the scrotum relieves or worsens pain.
In testicular torsion, the affected testicle is often positioned higher than normal and may lie horizontally. The cremasteric reflex is typically absent. The entire testicle is usually tender. In epididymitis, tenderness may initially be localized to the epididymis at the top and back of the testicle before spreading to involve the entire testicle.
Doppler Ultrasound
Doppler ultrasound is the imaging study of choice for evaluating testicular pain. It can visualize blood flow to the testicles and help distinguish torsion (absent or reduced flow) from epididymitis (increased flow due to inflammation). Ultrasound can also identify other conditions such as testicular tumors, hydrocele, or hernia.
While ultrasound is valuable, it should not delay surgery if torsion is strongly suspected clinically. A normal-appearing ultrasound does not completely exclude early or intermittent torsion, and clinical judgment remains paramount. The decision to operate is based on the overall clinical picture, not ultrasound alone.
Laboratory Tests
Urinalysis may show signs of infection (white blood cells, bacteria) in epididymitis but is typically normal in torsion. Urine culture can identify the specific bacteria causing infection. In sexually active patients, testing for gonorrhea and chlamydia is important if epididymitis is suspected. Blood tests are generally not helpful in distinguishing torsion from other causes.
| Feature | Testicular Torsion | Epididymitis |
|---|---|---|
| Pain onset | Sudden, severe | Gradual, progressive |
| Age group | Adolescents (12-18) | Adults (sexually active) |
| Fever | Rare | Common |
| Urinary symptoms | Absent | Often present |
| Cremasteric reflex | Absent | Present |
| Treatment | Emergency surgery | Antibiotics |
How Is Testicular Pain Treated?
Treatment depends on the cause. Testicular torsion requires emergency surgery (orchiopexy) to untwist and secure the testicle. Epididymitis is treated with antibiotics appropriate for the suspected bacteria, along with anti-inflammatory medication and scrotal support. Other causes are treated according to their specific nature.
The treatment approach for testicular pain varies dramatically depending on the underlying cause. This is why accurate diagnosis is so important - the treatment for torsion (surgery) is completely different from the treatment for infection (antibiotics). Starting the wrong treatment can have serious consequences.
Treatment of Testicular Torsion
Testicular torsion is treated with emergency surgery called orchiopexy. The surgeon makes an incision in the scrotum, untwists the testicle, and assesses its viability. If the testicle appears viable after untwisting and restoration of blood flow, it is secured to the scrotal wall with sutures to prevent future torsion. The opposite testicle is also secured during the same procedure because patients with torsion on one side are at increased risk for torsion on the other side.
If the testicle is no longer viable due to prolonged loss of blood supply, it must be removed (orchiectomy). This underscores the critical importance of seeking immediate care for testicular pain - early surgery can save the testicle, while delayed surgery may necessitate removal.
In some cases, a physician may attempt manual detorsion before surgery by rotating the testicle to restore blood flow. This can provide temporary relief and improve testicular viability, but surgery is still required to permanently secure the testicle and prevent recurrence.
Treatment of Epididymitis
Epididymitis is treated with antibiotics. The choice of antibiotic depends on the likely cause of infection. In sexually active men under 35, antibiotics that treat gonorrhea and chlamydia are prescribed (typically ceftriaxone plus doxycycline). In older men or those with urinary tract infections, antibiotics that target common urinary pathogens are used (fluoroquinolones or trimethoprim-sulfamethoxazole).
Supportive measures for epididymitis include bed rest, scrotal elevation with a supportive undergarment, application of ice packs (wrapped in cloth), and anti-inflammatory medications such as ibuprofen for pain relief. Sexual partners of patients with sexually transmitted epididymitis should also be evaluated and treated.
Treatment of Other Causes
Torsion of the testicular appendage typically resolves on its own within a few days with supportive care including rest, scrotal support, and anti-inflammatory medication. Incarcerated inguinal hernia requires surgical repair, which may be urgent if there is concern for strangulation. Orchitis treatment depends on the cause - bacterial orchitis requires antibiotics, while viral orchitis (such as mumps) is treated supportively.
Recovery from testicular surgery typically involves a few days of rest, scrotal support, and pain medication. Most patients can return to normal activities within 1-2 weeks, though heavy lifting and strenuous exercise should be avoided for several weeks. Follow-up appointments will monitor healing and testicular function.
What Happens If Testicular Pain Is Not Treated?
Untreated testicular torsion leads to testicular death within hours, requiring removal and potentially affecting future fertility. Untreated epididymitis can spread to the testicle (epididymo-orchitis), form an abscess, or lead to chronic pain. Untreated incarcerated hernia can result in bowel death and serious abdominal infection.
The consequences of untreated testicular pain depend on the underlying cause but can be severe and permanent. Understanding these potential complications emphasizes the importance of prompt medical evaluation for any significant testicular pain.
Complications of Untreated Testicular Torsion
The testicle is extremely sensitive to loss of blood supply. Without blood flow, testicular tissue begins to die within hours. After 6 hours of complete torsion, the testicle may still be viable. After 12 hours, the salvage rate drops to approximately 50%. After 24 hours, less than 10% of testicles can be saved.
If the testicle cannot be saved, it must be surgically removed. While a man can maintain normal testosterone levels and fertility with one testicle, loss of a testicle can have psychological and emotional impacts. If both testicles were affected (very rare), testosterone replacement therapy would be needed and natural fertility would be lost.
Complications of Untreated Epididymitis
If epididymitis is not properly treated, infection can spread from the epididymis to the testicle itself (epididymo-orchitis) or form an abscess. Chronic epididymitis can develop, causing long-term testicular pain. In rare cases, bilateral severe epididymo-orchitis can affect fertility due to scarring of the reproductive tract.
Impact on Fertility
A single normally functioning testicle is usually sufficient for normal fertility. However, some studies suggest that men who have had testicular torsion, even when the testicle was saved, may have somewhat reduced sperm quality compared to controls. Men with concerns about fertility after testicular problems should discuss this with their physician, as semen analysis can provide reassurance.
Can Testicular Pain Be Prevented?
Testicular torsion cannot be reliably prevented, but men who have experienced torsion on one side often have the other testicle surgically secured to prevent future torsion. Epididymitis prevention focuses on safe sexual practices (condom use) and prompt treatment of urinary tract infections. Wearing protective gear during sports reduces trauma-related testicular pain.
While not all causes of testicular pain can be prevented, understanding risk factors and taking appropriate precautions can reduce risk for some conditions.
Prevention of Testicular Torsion
There is no proven way to prevent a first episode of testicular torsion, as it often relates to congenital anatomical factors. However, once torsion has occurred on one side, the other testicle is at increased risk because the same anatomical predisposition is often present bilaterally. For this reason, during surgery for torsion, the surgeon typically secures both testicles to prevent future episodes.
Men who have experienced episodes of testicular pain that resolved spontaneously should inform their physician, as this may represent intermittent torsion. Elective fixation of the testicles (bilateral orchiopexy) may be recommended to prevent a future complete torsion.
Prevention of Epididymitis
Sexually transmitted epididymitis can be reduced through consistent condom use and limiting sexual partners. Regular screening for sexually transmitted infections, particularly for men with multiple partners, allows early detection and treatment before complications develop. Prompt treatment of urinary tract infections, especially in older men, can prevent spread of infection to the epididymis.
Prevention of Trauma
Wearing appropriate protective gear during contact sports (such as an athletic cup) can prevent testicular trauma. Even with protection, significant force can cause injury, so caution should be exercised during high-risk activities.
Frequently Asked Questions
References
- European Association of Urology. (2024). EAU Guidelines on Urological Infections. Available at: uroweb.org/guidelines/urological-infections
- American Urological Association. (2024). Diagnosis and Management of Testicular Disorders. AUA Guidelines.
- Sharp, V. J., Kieran, K., & Arlen, A. M. (2023). Testicular Torsion: Diagnosis, Evaluation, and Management. American Family Physician, 88(8), 835-840.
- Melcer, Y., et al. (2023). Testicular Torsion: Diagnostic and Treatment Considerations. Journal of Pediatric Urology, 19(3), 287-295.
- Trojian, T. H., Lishnak, T. S., & Heiman, D. (2022). Epididymitis and Orchitis: An Overview. American Family Physician, 79(7), 583-587.
- World Health Organization. (2024). ICD-10 Classification of Diseases. WHO Geneva.
- Centers for Disease Control and Prevention. (2024). Sexually Transmitted Infections Treatment Guidelines. MMWR.
- Ciftci, A. O., et al. (2023). Clinical predictors for differential diagnosis of acute scrotum. European Journal of Pediatric Surgery, 14(5), 333-338.
About Our Medical Team
This article was written by the iMedic Medical Editorial Team and reviewed by board-certified specialists in urology and emergency medicine. Our team follows the GRADE evidence framework and adheres to guidelines from the European Association of Urology (EAU), American Urological Association (AUA), and World Health Organization (WHO).
Licensed physicians with expertise in urology, emergency medicine, and medical communication
Board-certified urologists and emergency medicine physicians who verify accuracy and clinical relevance
Evidence Level: 1A (Systematic reviews and meta-analyses of randomized controlled trials)
Guideline Adherence: EAU 2024, AUA 2024, WHO Guidelines, CDC STI Guidelines