An adult male complains of dull to severe scrotal pain
developing over a period of hours to a day, and radiating to
the ipsilateral lower abdomen or flank. There may be a
history of recent urethritis, prostatitis or prostatectomy
(allowing ingress to bacteria), straining with lifting a
heavy obiect, or sexual activity with a full bladder
(allowing reflux of urine). There may be fever, nausea, or
urinary urgency or frequency. The epididymis, is tender, swollen, warm, and difficult to separate from the firm, nontender testicle. Increasing
inflammation can extend up the spermatic cord and fill the
entire scrotum, making examinations more difficult, as well
as produce frank prostatitis or cystitis. The rectal exam
therefore may reveal a very tender, boggy prostate.
What to do:
Ascertain that the testicle is normal in position and
perfusion. Doppler ultrasound may help pick up a drop-off
in arterial flow from spermatic cord to testicle in
Palpate and ausculate, the scrotum to rule out a hernia.
Gently palpate the prostate once. Culture urine and/or any
urethral discharge to identify a bacterial organism.
On rare occasions, for severe pain, you may infiltrate the
spermatic cord above the inflammation with local
anesthetic for better palpation and diagnosis (e.g., 1%
lidocaine without epinephrine). Lesser pain may respond to
antiinflammatory analgesics (e.g., Motrin, aspirin with
Prescribe antibiotics for likely organisms. In men under
35, ceftriaxone 250 mg im in the ED and a prescription for
doxycycline 100mg bid for 10 days should eradicate N.
gonorrhea and C. trachomatis. An alternative treatment is ofloxacin (Floxin) 300mg bid x 10d. In men over 35, ciprofloxacin 500mg bid for 10-14 days may be better for gram negative bacteria.
Arrange for 2-3 days of strict bedrest, with the scrotum
elevated, and urologic followup.
What not to do:
Do not miss testicular torsion. It is far better to have
the urologist explore the scrotum and find epididymitis
than to delay and lose a testicle to ischemia (which can
happen in only 4 hours).
Testicular torsion is more likely in children and
adolescents, and has a more sudden onset, although it can be
recurrent and is often related to exertion or direct trauma. If the spermatic
cord is twisted, the testicle may be high, the
epididymis may be in other than its normal posterior
position, and there will most likely be no cremasteric reflex. A testicular scan can help differentiate torsion
from the sometimes similar presentation of acute
epididymitis. When torsion is highly suspected you may try a
therapeutic detorsion by exter nally rotating the testicle
180 degrees with the patient standing
Caldamone AA, Valvo JR, Altebarmakian VK et al: Acute scrotal swelling in children. J Ped Surg 1984;19:581-584.
Knight PJ, Vassy LE: The diagnosis and treatment of the acute scrotum in children and adolescents. Ann Surg 1984;200:664-673.