Version July 2025
INTRODUCTION —
The acute scrotum is defined as moderate to severe scrotal pain that develops over the course of minutes to one to two days. The spectrum of conditions affecting the scrotum and its contents ranges from acute pathologic events that require immediate surgical intervention to incidental findings that are managed with supportive care and patient reassurance.
This topic addresses the diagnostic evaluation and initial management of the acute scrotum in adults, which is typically due to testicular torsion, perineal necrotizing fasciitis (Fournier's gangrene), or acute epididymitis. This topic also addresses the clinical management of testicular torsion. Further details on the evaluation and management of necrotizing fasciitis and acute epididymitis and traumatic injury to the male external genitalia are discussed separately:
●(See "Necrotizing soft tissue infections".)
●(See "Surgical management of necrotizing soft tissue infections".)
●(See "Acute epididymitis in adolescents and adults".)
●(See "Traumatic injury to the male anterior urethra, scrotum, and penis".)
Nonacute scrotal conditions in adults and scrotal disorders in children and adolescents are also discussed separately:
●(See "Nonacute scrotal conditions in adults".)
●(See "Evaluation of nontraumatic scrotal pain or swelling in children and adolescents" and "Causes of scrotal pain in children and adolescents".)
NORMAL ANATOMY —
The testis, tunica vaginalis, epididymis, spermatic cord, appendix testis, and appendix epididymis are anatomic structures that may be involved in 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, approximately 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 that encapsulates a potential space that encompasses the anterior two-thirds of the testis. Different types of fluid may accumulate within the tunica vaginalis (eg, serum 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 —
The primary goal of initial evaluation is to differentiate between acute epididymitis, necrotizing fasciitis (Fournier's gangrene), and testicular torsion. In practice, acute epididymitis is the most common cause. Necrotizing fasciitis and testicular torsion are surgical emergencies that require prompt identification and escalation of care.
Identification of urgent conditions — The initial evaluation of acute scrotal pain should focus on prompt identification and management of surgically urgent conditions. This approach is summarized in the algorithm (algorithm 1) and in the table (table 1).
Rule out perineal necrotizing fasciitis — Systemic illness, hemodynamic instability, or rapidly progressive erythema and edema of the overlying soft tissues of the scrotum strongly suggests perineal necrotizing fascitis (Fournier's gangrene) (picture 1), which is a necrotizing fasciitis of the perineum. It is typically seen in patients with diabetes mellitus; it can also occur in patients with urethral trauma, immunocompromise, or a chronic indwelling urethral catheter. Pain may start on the anterior abdominal wall and migrate into the gluteal muscles and scrotum. Physical examination may demonstrate tense edema of the skin, blisters/bullae, crepitus, or subcutaneous gas. If perineal necrotizing fasciitis is suspected, urgent surgical or urologic evaluation should be prioritized over additional diagnostic workup.
When there is clinical evidence of progressive soft tissue infection and perineal necrotizing fasciitis is suspected, imaging studies should not delay surgical exploration and broad-spectrum antibiotic therapy (see "Necrotizing soft tissue infections", section on 'Treatment'). However, in equivocal cases, imaging (computed tomography [CT] in particular), may assist in diagnosis. Suggestive findings on imaging include air along the fascial planes or deeper tissue involvement. (See "Necrotizing soft tissue infections", section on 'Radiographic imaging'.)
Ultrasound to evaluate for testicular torsion — Testicular ultrasound should be prioritized to quickly evaluate for testicular torsion, ideally within the first hour of presentation, unless there is convincing clinical evidence for an alternate etiology [1]. In practice, ultrasound is performed in most patients presenting with acute scrotal pain (algorithm 1). If ultrasound is not available within eight hours of symptom onset, we recommend transfer to a facility with this capability. Because delayed surgical intervention could lead to loss of the testis and other complications [2-4], helicopter transport should be considered if ground transfer of a patient could result in significant delay in a remote setting. Clinical manifestations of torsion are reviewed below. (See 'Subsequent evaluation' below and 'Clinical manifestations' below.)
●Ultrasound features of torsion – Testicular ultrasound has been shown to have a sensitivity and specificity as high as 82 and 100 percent, respectively, for the diagnosis of testicular torsion [5-7]. It is important to specify a thorough ultrasound evaluation of the spermatic cord up to the level of the internal ring and not just limit the examination to the scrotum. Decreased or absent testicular perfusion or twisting of the spermatic cord suggest a presumptive diagnosis of testicular torsion. If ultrasound identifies testicular torsion, urgent surgical or urologic evaluation should be prioritized over additional diagnostic workup. (See 'Early referral for surgical evaluation' below.)
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") [8,9]. In a study of 919 patients (mean age nine 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 [10].
Testicular ultrasound can also diagnose other etiologies of scrotal pain. (See 'Ancillary testing' below.)
●Surgical evaluation for equivocal results or when ultrasound is not available
•If ultrasound results are equivocal for torsion and clinical suspicion is high, or other etiologies of acute scrotal pain are not identified, urologic consultation and exploratory surgical evaluation are indicated [11]. While testicular ultrasound can identify most cases of testicular torsion, some cases may escape ultrasound detection. This is especially true in younger patients and patients with intermittent torsion or 180-degree torsion [5,6]. Ultrasound technique may also play a role [7].
•Urologic consultation and exploratory surgical evaluation are also indicated when clinical suspicion is high and ultrasound is not available within eight hours of symptom onset. Clinicians must weigh the potential benefit of treatment delay for ultrasound evaluation with the risk of testicular nonviability from delayed detorsion. In such patients, manual detorsion is an acceptable first step, as symptomatic improvement and cord lengthening following manual detorsion also support the diagnosis [12,13]. Techniques for manual detorsion are discussed separately. (See 'Manual detorsion as a temporizing measure' below and 'Early referral for surgical evaluation' below.)
Subsequent evaluation — Patients with a high index of suspicion for perineal necrotizing fasciitis or testicular torsion should be referred for urgent surgical evaluation (see 'Identification of urgent conditions' above). For all other patients, the combination of clinical features and ultrasound findings informs the diagnostic evaluation, especially in situations where ultrasound results are pending or equivocal (algorithm 1).
History — The history should focus on 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, discharge) (table 1). Patients should be asked about sexual activity, including insertive anal intercourse. They should also be asked about lower urinary tract symptoms suggestive of BPH or obstructive uropathy and recent urologic instrumentation, as these are risk factors for sexually transmitted epididymitis and epididymitis secondary to urinary tract infection, respectively.
●Timing – The onset of pain assists with determining the etiology:
•Acute onset – Acute, rapidly progressive pain suggests perineal necrotizing fasciitis (Fournier's gangrene) or testicular torsion. Additional presenting features of necrotizing fasciitis are discussed above. (See 'Rule out perineal necrotizing fasciitis' above.)
•Gradual onset – Gradual onset of testicular pain over several days suggests epididymitis, epididymo-orchitis, or orchitis, especially in the presence of lower urinary tract symptoms.
●Location of pain – The location of pain can suggest the etiology:
•Posterior – Pain localized to the posterior aspect of the testis suggests epididymitis. More advanced cases may present with secondary testicular pain and swelling (epididymo-orchitis). Scrotal wall erythema and a reactive hydrocele may be present.
•Anterior – In torsion of the appendix testis, pain is localized to the anterior superior pole of the testis (figure 2).
•Diffuse – Diffuse or nonspecific scrotal pain may be consistent with testicular torsion, epididymitis, and other diagnoses; further diagnostic workup is necessary in these cases.
•Bilateral – Bilateral scrotal involvement is highly suggestive of mumps.
Physical examination — The abdomen, inguinal region, and scrotal skin and contents should be carefully examined (figure 1). Normal scrotal anatomy is reviewed above. (See 'Normal anatomy' above.)
●Visual inspection – When testicular torsion is present, overlying erythema of the scrotal wall and testicular swelling may be evident 12 to 24 hours after the onset of pain. The testis may be slightly elevated due to shortening of the spermatic cord, or it may be oriented horizontally, known as "bell clapper" deformity (figure 3).
In acute epididymitis, scrotal wall erythema and a reactive hydrocoele may also be present.
In patients with torsion of the appendix testis, the "blue dot" sign (picture 2), may be noted on the scrotal wall. While uncommon, this finding strongly suggests the diagnosis when present.
●Palpation – The finding of a tender mass or "knot" superior to the testis is also highly suggestive of torsion. A mass may also suggest other potential causes of scrotal pain, such as testicular cancer.
A positive Prehn sign (in which manual elevation of the scrotum relieves pain) is more often seen with epididymitis than with testicular torsion.
If palpation does not localize pain to the scrotum, referred pain and alternate etiology should be considered. (See 'Other etiologies of acute scrotal pain' below.)
●Cremasteric reflex – The cremasteric reflex assists with ruling out testicular torsion. With the patient supine, lightly stroke the medial portion of the thigh in a downward direction. In a normal response, the cremaster muscle contracts to pull up the ipsilateral testis superiorly.
•If the cremasteric reflex is negative (the testis does not pull up when the ipsilateral thigh is stroked), the possibility of testicular torsion should be investigated.
•If the cremasteric reflex is positive (the testis pulls up when the ipsilateral thigh is stroked), testicular torsion is less likely. Acute epididymo-orchitis or other etiology is more likely. (See 'Other etiologies of acute scrotal pain' below.)
Cremasteric reflex findings should be interpreted cautiously; an intact cremasteric reflex is most often seen in boys between 30 months and 12 years of age and is less consistent in older males; thus, a negative cremasteric reflex does not necessarily indicate testicular torsion and, in some cases, may reflect loss of the cremaster reflex due to age. Diagnostic ultrasound can further guide diagnosis when the cremasteric reflex is negative. (See 'Ultrasound to evaluate for testicular torsion' above.)
●Inguinal hernia examination – The groin should be examined to rule out an inguinal hernia as a cause of referred scrotal pain. 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 upper scrotum. If bowel sounds are noted on auscultation of the scrotum, this is highly suggestive of inguinal hernia. Strangulated hernias may be associated with severe pain localized to the groin or abdomen (picture 3).
●Prostate examination – A tender prostate on examination is suggestive of prostatitis, which can present alongside epididymitis.
Ancillary testing
●Testicular ultrasound – As above, ultrasound is a key early step in the evaluation of acute scrotal pain, and especially when testicular torsion is suspected [1]. (See 'Ultrasound to evaluate for testicular torsion' above.)
Exceptions include situations where imaging may delay urgent intervention (eg, when perineal necrotizing fasciitis [Fournier's gangrene] is suspected) or in unambiguous cases of nonsurgical etiologies, as diagnosed by an experienced clinician (eg, epididymitis, torsion of the appendix testis). (See "Acute epididymitis in adolescents and adults" and 'Other etiologies of acute scrotal pain' below.)
If testicular ultrasound was not already obtained and the diagnosis remains uncertain after initial clinical evaluation, ultrasound is the appropriate next step to assist with establishing the diagnosis. When the cause of scrotal pain is not evident after initial evaluation and testicular ultrasound, urology consultation is advised (algorithm 1). (See 'When to refer' below.)
●Laboratory testing – If acute epididymitis is suspected, urine and other testing should be sent to detect inflammation, confirm a pathogen, and screen for associated sexually transmitted infections. Point-of-care testing, when available, assists with prompt diagnosis. These details are discussed elsewhere. (See "Acute epididymitis in adolescents and adults", section on 'Diagnostic approach'.)
Laboratory testing does not have a central role in the evaluation of testicular torsion.
WHEN TO REFER —
Patients with acute scrotal pain require referral for emergency care or urologic consultation in situations where urgent surgical intervention is needed (eg, perineal necrotizing fasciitis [Fournier's gangrene] and testicular torsion) and may also require referral in cases of diagnostic uncertainty, where the underlying etiology of scrotal pain remains unclear after initial evaluation.
Patients who warrant emergency care — Many patients will present for initial evaluation to the emergency department. For others, referral for emergency care is indicated as follows:
●Perineal necrotizing fasciitis and testicular torsion – Patients clinically suspected of having testicular torsion or perineal necrotizing fasciitis (Fournier's gangrene) should be referred to the emergency department for urgent evaluation by surgery or urology. These are surgical emergencies requiring prompt escalation of care.
●Selected patients with acute epididymitis – 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). These patients should be referred to the emergency department for prompt initiation of antibiotic therapy and supportive care for sepsis.
Patients with suspected epididymitis without signs of critical illness or hemodynamic instability may be managed as an outpatient and monitored for response to empiric treatment (algorithm 2). (See "Acute epididymitis in adolescents and adults".)
Cases of diagnostic uncertainty — When the cause of scrotal pain is not evident after the initial evaluation, atypical presentations of testicular torsion (eg, intermittent testicular torsion) or acute epididymitis should be considered, in addition to other causes of scrotal pain. These include trauma, postvasectomy pain, testicular cancer, immunoglobulin A vasculitis (Henoch-Schönlein purpura), acute idiopathic scrotal edema, varicocele, and referred pain (diagnosis of exclusion) (table 1).
In these cases, we advise an outpatient scrotal ultrasound (if not already performed) and urology consultation to guide further diagnosis and treatment (algorithm 1). (See 'Other etiologies of acute scrotal pain' below.)
MANAGEMENT OF COMMON CAUSES —
Management is guided by clinical suspicion of etiology (algorithm 1).
Perineal necrotizing fasciitis (Fournier's gangrene) — Fournier's gangrene is a necrotizing fasciitis (mixed aerobic/anaerobic infection) of the perineum that often involves the scrotum. The incidence of perineal necrotizing fasciitis is rare; in one United States population-based study, the overall incidence rate was 1.6 cases of Fournier's gangrene per 100,000 males per year [14]. However, the mortality rate is as high as 16 to 40 percent in case series, due to rapid progression of fulminant tissue destruction and systemic toxicity [15-18]. Therefore, prompt diagnosis and surgical evaluation are critical.
Treatment of necrotizing fasciitis consists of early aggressive surgical exploration with debridement of necrotic tissue, broad-spectrum antibiotic therapy, and hemodynamic support as needed [19]. Patients with necrotizing fasciitis of the perineum may ultimately require cystostomy, colostomy, or orchiectomy [14-18]. (See 'Rule out perineal necrotizing fasciitis' above and "Surgical management of necrotizing soft tissue infections".)
Testicular torsion
Epidemiology and pathophysiology — Testicular torsion can occur at any age but is less common in adults than in neonates and postpubertal boys [20]. Each year, testicular torsion occurs in approximately 1 in 4000 male individuals younger than 25 years of age; the majority of these cases occur in children or adolescents. Among older adults, torsion occurs less frequently but remains an important cause of acute, severe scrotal pain. As an example, in one retrospective review of 44 hospitalized patients with testicular torsion, 39 percent were males 21 years and older [21]. In other studies of adult males hospitalized with acute scrotal pain, the prevalence of testicular torsion has ranged from 25 to 50 percent [20,22-25]. Testicular torsion in children is discussed separately. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion'.)
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 spontaneously or after an inciting event (eg, trauma, vigorous physical activity).
Torsion initially obstructs venous return. Subsequent equalization of venous and arterial pressures compromises arterial flow, resulting in testicular ischemia. The degree of ischemia depends on the duration of torsion and the degree of rotation of the spermatic cord [26].
Clinical manifestations — Patients with testicular torsion report acute onset scrotal pain of less than 12 hours duration; nausea, vomiting, and abdominal pain may be present. In some cases, physical activity or minor trauma precede the onset of pain. Physical examination may reveal a diffusely edematous, tender scrotum; the testis may be slightly elevated due to shortening of the spermatic cord, or it may be oriented horizontally, known as "bell clapper" deformity (figure 3). A tender mass or "knot" superior to the testis may be present. The cremasteric reflex is usually negative (eg, the testis does not pull up when the ipsilateral thigh is stroked), however this finding is nonspecific and may vary by age. (See 'Subsequent evaluation' above.)
Management
Early referral for surgical evaluation — Patients clinically suspected of having testicular torsion by history, examination, or ultrasound require urgent referral to an emergency department for surgical or urologic evaluation (algorithm 1). (See 'Ultrasound to evaluate for testicular torsion' above.)
Treatment for suspected testicular torsion is urgent surgical exploration with intraoperative detorsion. Fixation should be performed for both the involved testis and contralateral, uninvolved testis to prevent future episodes, as inadequate gubernacular fixation is usually a bilateral defect.
Intraoperative detorsion should be performed within eight hours of the onset of pain. If surgery is not available within eight hours of symptom onset, clinicians should attempt manual detorsion while awaiting surgical transfer. (See 'Manual detorsion as a temporizing measure' below.)
Delay in detorsion may lead to progressively higher rates of testicular nonviability. Studies suggest that the testis suffers irreversible damage after eight hours of ischemia from testicular torsion [26-28]; however, the testicular salvage rate also varies based upon the degree of torsion. High-quality data on surgical outcomes of torsion in adults are lacking, and recommendations in this population are extrapolated from studies in children. In one pediatric study, investigators quoted a testicular salvage rate of 90 percent if detorsion occurred less than six hours from the onset of symptoms; this rate fell to 50 percent after 12 hours and to less than 10 percent after 24 hours [3]. In another pediatric series of testicular survival after a torsion event, the following were found: detorsion within four to six hours resulted in 97 to 100 percent viability, detorsion after 12 hours resulted in 20 to 61 percent viability, and detorsion after 24 hours resulted in 0 to 24 percent viability [4].
Color Doppler ultrasonography has been used to predict the outcome of testicular salvage. In one pediatric 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 [29]. 89 percent of patients with homogeneous echotexture had testicular viability at exploration. The authors conclude that, while surgical exploration is indicated in all cases of torsion, surgery should be pursued emergently when ultrasound findings indicate homogenous echotexture, as the potential for testicular salvage is high in these patients.
Manual detorsion as a temporizing measure — If surgery is not available within eight hours of symptom onset, an attempt to detorse the testicle manually is warranted. The goal is to improve or restore testis perfusion while definitive surgical management is arranged (figure 5):
●Analgesia – Manual detorsion in adults is typically performed without local or general anesthesia, due to concern for masking continued torsion. If necessary, short-acting analgesic medications can alleviate discomfort during the procedure.
●Procedure – Manual detorsion is performed by grasping the affected testicle and rotating it outwards within the scrotum (medial to lateral) through one to two full 360-degree turns (figure 5).
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 over one-third of cases [12,30]. Thus, if outward, lateral detorsion produces no relief, then medial rotation should be attempted. Occasionally, the degree of twisting of the testis may range from 180 to 720°, requiring multiple rounds of detorsion.
●Postprocedure assessment – Successful detorsion is suggested by [31]:
•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
●Surgical follow-up – Manual detorsion should be followed by surgical exploration, as the success rate of manual detorsion has been as low as 26 percent in some studies [26,32]. In addition, residual torsion may be present that can be further relieved intraoperatively, and orchiopexy (securing the testicle to the scrotal wall) is indicated to prevent torsion recurrence [30].
Observational studies in children have suggested relief of pain and improved testicular salvage with manual detorsion. These data and management of torsion in children are found elsewhere. (See "Causes of scrotal pain in children and adolescents", section on 'Manual detorsion'.)
Prognosis — Testicular torsion can affect testicular viability and fertility:
●Complications from testicular ischemia – The extent of damage from ischemia is dependent upon the duration of torsion and degree of rotation of the spermatic cord [33]. Extended periods of ischemia (>8 hours) may cause infarction of the testis with necrosis, requiring orchiectomy.
When compared with children, adults with torsion have longer time to presentation and greater time between presentation and surgery, leading to lower rates of testicular viability postsurgery. In one retrospective study, the testicular salvage rates of patients age <21 years and age ≥21 years were 70 and 41 percent, respectively [21]. While the time to presentation was the most important factor affecting the salvage rate, adult males also had a greater degree of cord twisting than the younger group, which may partly explain the difference in outcomes.
Prolonged ischemia may also lead to a "testicular compartment syndrome," which may arise even after detorsion. In such cases, reperfusion and parenchymal edema in the space confined by the inelastic tunica albuginea cause increased pressure, which impairs parenchymal blood flow.
●Fertility – If torsion has resulted in ischemic damage, infertility may result, even with a normal contralateral testis. This may be due to several factors, including loss of overall germ cell volume, disruption of the immunologic "blood-testis" barrier, and exposure of antigens from germ cells and sperm to the general circulation, with subsequent development of antisperm antibodies [34,35]. However, concern for decreased fertility after torsion may be overestimated; in one study of 63 patients with testicular torsion treated with either orchiopexy or orchiectomy, pregnancy rates and interval to pregnancy were similar to rates in the general population [36].
Acute epididymitis — The evaluation and management of acute infectious epididymitis and epididymo-orchitis are discussed separately. (See "Acute epididymitis in adolescents and adults".)
OTHER ETIOLOGIES OF ACUTE SCROTAL PAIN —
When the cause of scrotal pain is not evident after initial evaluation, other causes of scrotal pain should be considered. These include trauma, postvasectomy pain, testicular cancer, immunoglobulin A (IgA) vasculitis (Henoch-Schönlein purpura), acute idiopathic scrotal edema, and other less common causes. In these settings, testicular ultrasound is advised, if not already performed, in addition to outpatient urology evaluation (algorithm 1).
●Torsion of the appendix testis – Unlike testicular torsion, torsion of the appendix testis is managed conservatively and is not a surgical emergency. The appendix testis is a vestigial structure on the anterosuperior aspect of the testis (figure 2). The pedunculated shape of the appendix testis predisposes it to torsion, though this occurs rarely in adults [37]. Most cases occur in children between the ages of 7 and 14 years, with a mean age of 10.6 years [38]. (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 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), caused by infarction and necrosis of the appendix testis. This finding, while uncommon, strongly suggests the diagnosis when present [26,39].
If the diagnosis is unclear on physical examination, a scrotal ultrasound can demonstrate the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area [40]. 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 is supportive, including local application of ice and nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for discomfort and swelling. Recovery is gradual, with symptoms often lasting for weeks to months. Surgical excision of the appendix testis is reserved for patients who have persistent pain despite these measures.
●Trauma – It is common for males 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 emergent surgical repair. Uncomplicated injuries are managed conservatively. Young males who engage in sports where blunt scrotal injury risk is high (eg, hockey, lacrosse) should wear appropriate protection. (See "Traumatic injury to the male anterior urethra, scrotum, and penis".)
●Postvasectomy pain – Patients who have had a vasectomy may have firmness in the entire epididymis secondary to ductal obstruction. Some males 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 consists 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 inguinal canal into the scrotum can present with pain and a scrotal mass. Pain with inguinal hernias is most likely to be localized in the groin or abdomen rather than the scrotum. A strangulated hernia may be associated with severe pain (picture 4).
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 (see 'Subsequent evaluation' above). Bowel sounds may be audible in the scrotum.
Groin ultrasound or CT scan may be helpful if strangulation is suspected. 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 5); bilateral involvement is present in up to 30 percent of cases. Diagnosis is suspected clinically but can be confirmed serologically. (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'.)
●IgA vasculitis (Henoch-Schönlein purpura) – Immunoglobulin A (IgA) vasculitis is a systemic vasculitis characterized by nonthrombocytopenic purpura, arthralgia, kidney disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. Scrotal pain can be the presenting symptom, and its onset may be acute or insidious.
Scrotal ultrasound is useful to distinguish IgA vasculitis from testicular torsion. Ultrasound findings in IgA vasculitis include marked edema of the scrotal skin and contents with intact vascular flow in the testes. Management the vasculitis is discussed separately; management of scrotal pain is supportive. (See "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis" and "IgA vasculitis (Henoch-Schönlein purpura): Management".)
●Acute idiopathic scrotal edema – Some males develop significant scrotal or penile edema of unknown etiology, usually without pain [41,42]. The condition has been more often reported in children [42]. 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 males 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 [41]. Management consists of scrotal elevation, and the condition generally resolves within 48 hours [41].
●Varicocele – Varicocele typically presents with dull, intermittent scrotal pain. It is caused by dilation of the spermatic veins, which most commonly occurs on the left due to the angle at which the left spermatic vein empties into the left renal vein. On examination, patients exhibit palpable swollen veins superior to the testicle, commonly referred to as "a bag of worms." (See "Nonacute scrotal conditions in adults", section on 'Varicocele'.)
●Referred pain – Males 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 [43]. They include abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, pelvic floor muscle dysfunction, and postherniorrhaphy state.
INFORMATION FOR PATIENTS —
UpToDate 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 email 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 topic (see "Patient education: Epididymitis and orchitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition and anatomy – The acute scrotum is defined as moderate to severe scrotal pain that develops over the course of minutes to up to two days. The testis, tunica vaginalis, epididymis, spermatic cord, appendix testis, and appendix epididymis may be involved in acute scrotal conditions (figure 1). (See 'Normal anatomy' above.)
●Identification of urgent conditions – Initial evaluation of acute scrotal pain should prioritize prompt identification of urgent conditions (algorithm 1).
•Perineal necrotizing fasciitis – Systemic illness, hemodynamic instability, or rapidly progressive erythema and edema of the overlying soft tissues strongly suggests necrotizing fasciitis of the perineum (Fournier's gangrene) (picture 1). Physical examination may demonstrate tense edema of the skin, blisters/bullae, crepitus, or subcutaneous gas. If suspected, urgent surgical or urologic evaluation is warranted. (See 'Rule out perineal necrotizing fasciitis' above and 'Perineal necrotizing fasciitis (Fournier's gangrene)' above.)
•Testicular torsion – Patients with testicular torsion report acute onset scrotal pain of less than 12 hours duration. Physical examination may reveal a diffusely edematous, tender scrotum; the testis may be slightly elevated due to shortening of the spermatic cord, or it may be oriented horizontally, known as "bell clapper" deformity (figure 3).
Testicular ultrasound should be prioritized for prompt diagnosis of torsion, ideally within the first hour of presentation. (See 'Ultrasound to evaluate for testicular torsion' above.)
Some cases of torsion may escape ultrasound detection. If clinical suspicion is high or other, more likely etiologies of acute scrotal pain are not identified, exploratory surgical evaluation should be pursued. (See 'Subsequent evaluation' above.)
●Subsequent evaluation – If perineal necrotizing fasciitis and testicular torsion are not suspected, subsequent evaluation is guided by the history and physical examination (algorithm 1).
Key historical features include location and timing of pain, presence of fever and lower urinary tract symptoms, risk factors for sexually transmitted infections, and history of inguinal or scrotal surgery. The abdomen, inguinal region, and scrotal skin and contents should be carefully examined, including inguinal hernia examination and additional specialized maneuvers (figure 1). (See 'Subsequent evaluation' above.)
In most cases, testicular ultrasound should be performed, if not already obtained. If acute epididymitis is suspected, urine and blood testing are sent to detect inflammation, confirm a pathogen, and screen for associated sexually transmitted infections. (See 'Ancillary testing' above and "Acute epididymitis in adolescents and adults", section on 'Diagnostic approach'.)
●When to refer – Patients with suspected testicular torsion or perineal necrotizing fasciitis should be referred to the emergency department for urgent evaluation by surgery or urology. (See 'When to refer' above.)
In cases of diagnostic uncertainty or when symptoms do not improve with presumptive treatment, atypical presentations of testicular torsion (eg, intermittent testicular torsion) or acute epididymitis should be considered, in addition to other causes of scrotal pain. Testicular ultrasound is indicated, if not already obtained, in addition to urology consultation (algorithm 1). (See 'Other etiologies of acute scrotal pain' above and 'Management of common causes' above.)
●Management of common causes – Management is guided by clinical suspicion of etiology (algorithm 1). (See 'Management of common causes' above.)
•Perineal necrotizing fasciitis – Treatment of necrotizing fasciitis consists of early, aggressive surgical exploration; broad-spectrum antibiotic therapy; and hemodynamic support as needed. Management of perineal necrotizing fasciitis is discussed separately. (See 'Perineal necrotizing fasciitis (Fournier's gangrene)' above and "Necrotizing soft tissue infections" and "Surgical management of necrotizing soft tissue infections".)
•Testicular torsion – Patients with suspected testicular torsion require urgent surgical evaluation and intraoperative detorsion. (See 'Testicular torsion' above and 'Early referral for surgical evaluation' above.)
If surgery is not available within eight hours of symptom onset, an attempt to detorse the testicle manually is warranted (figure 5). (See 'Manual detorsion as a temporizing measure' above.)
Extended periods of ischemia (>8 hours) increase the risk for additional complications, including testicular infarction. (See 'Prognosis' above.)
•Acute epididymitis or epididymo-orchitis – The evaluation and management of acute infectious epididymitis and epididymo-orchitis, including empiric antimicrobial regimens, are discussed separately (algorithm 2). (See "Acute epididymitis in adolescents and adults".)
●Other etiologies of acute scrotal pain – Other causes of acute scrotal pain include trauma, postvasectomy pain, testicular cancer, immunoglobulin A vasculitis (Henoch-Schönlein purpura), acute idiopathic scrotal edema, varicoceles, and additional less common causes. An outpatient scrotal ultrasound (if not already performed) and urology consultation are advised to guide further evaluation. (See 'Other etiologies of acute scrotal pain' above.)
