Scrotal/Testicular Pain & Swelling
There are multiple reasons why a man may have testicular and/or scrotal pain. The most common is simply getting knocked or kicked in the testicles. This can lead to intense pain that often causes a man to double over and feel like vomiting. However, this type of pain is typically short lived – only lasting a minute or so – even if the nausea sticks around for a few more minutes.
Testicular pain lasting more than a couple of minutes, the presence of lumps on or in the testicle, or swelling of the scrotum can indicate a medical issue that may need medical attention. Some pain/swelling may be due to issues going on elsewhere in the reproductive system but simply “felt” in the testicular/scrotal area. Other pain/swelling can be an urgent medical issue that needs to be taken care of immediately to prevent irreversible damage. Pain and/or swelling of the scrotum and testicles can be caused by some of the following issues:
Torsion of the Appendix Testes
Idiopathic Scrotal Swelling
Referred pain caused by inflammation in nearby structures
Medication side effects from certain drugs
Each of these conditions will be discussed in detail below. These may give you an idea of what may possibly be going on if you have pain or swelling in this region, but it’s always prudent to have a healthcare professional assess any issues. You don’t want to assume that it’s something minor when, in fact, it’s something major.
Your healthcare provider can often tell by the appearance, the description of the pain, or an examination of the scrotal area to determine which, if any, of the above issues a man may have. They may also test a man’s cremaster reflex. The cremaster reflex involves stroking the skin on the inner thigh. This should normally cause a muscular contraction reflex in the cremaster muscles in the scrotum causing the scrotum to tighten and rise closer to the body. Healthcare providers may also shine a light through the scrotum to see if light passes through or if the light is prevented from passing through the scrotum. A healthcare professional can also perform other tests to know for sure (some require imaging technology that are not available to men outside a healthcare setting). In many cases, an ultrasound of the scrotum and testicles will be performed to get a picture of the inside of the scrotum to see exactly what’s going on since different conditions can often present with similar symptoms.
You should be familiar with the normal appearance, texture, and feeling of your own scrotum and testicles. This comes by ensuring that you’re doing a monthly testicular self-exam as described by clicking HERE. Knowing what is normal for you will make it easier to recognize when something is out of the ordinary and to seek medical attention.
Testicular torsion is an EMERGENCY!!!!! If it is not treated within 12 hours, it can lead to death of the testicle and possibly infertility and hormone problems.
Testicular torsion is caused by a twisting or “kinking” of the spermatic cord, as seen below. This can lead to loss of blood flow to the testicle. It also kinks the nerves that go to the testicle; and as every man knows, these nerves can transmit a whole lot of pain. So, the pain that is elicited from this kinking is often SEVERE. It can come on suddenly out of nowhere causing intense pain and discomfort which can be incapacitating. Testicular torsion can occur at any age with just over half of the instances occurring before adulthood and just under half occurring during adulthood. However, the vast majority of cases occur during the mid-teens as the testicles begin to grow in size due to puberty.
This twisting is often caused due to inadequate fixation of the testicle to the scrotum by the scrotal ligament; and, more importantly, by attachment of the tunica vaginalis to the scrotum. This attachment of the testicle to the scrotum prevents testicular torsion from occurring in the majority of men; however, for men that have a weak attachment, the testicle is free to spin causing a kinking in the spermatic cord higher up. Either one or both testicles may be involved. In many cases, a severe torsion may cause the testicle to actually tilt, even as much as becoming horizontal in the scrotum (lying on its side).
The severe pain associated with testicular torsion comes on extremely rapidly and can be almost incapacitating. It can be due to an injury, rigorous activity, or even sexual stimulation – basically any movement of the scrotum can elicit this twisting. Sexual stimulation causes contraction of the cremaster muscle, causing the scrotum to lift. This movement can sometimes cause the testicle to spin if it’s not held in place securely. Some men will wake up in the middle of the night with severe pain that has been caused by a torsion precipitated by a nocturnal erection. When a healthcare provider examines a man with suspected torsion, the cremaster reflex is often absent (the scrotum will not rise or contract when the inner thigh is stroked).
Infertility can occur if sperm happens to escape the testicle/epididymis/vas deferens of the testicle in torsion. Normally, a man’s body and blood stream are not exposed to the sperm he produces. Sperm normally travel through the male reproductive tract without being exposed to blood or the man’s immune system. If sperm escapes the reproductive tract (such as into the scrotal sac itself), then the man’s immune system will produce antibodies against his own sperm and attack them wherever they may be found – even in the healthy testicle on the other side.
Treatment for torsion can require emergency surgery, usually within two hours. Again, the kink has to be worked out as fast as possible to prevent the death of the testicle due to lack of blood (also called hypoxia). A healthcare provider may also try to manually “untwist” the testicle. This should largely be performed only by a healthcare professional to prevent twisting the testicle even tighter. In testicular torsion, the twisting is almost always to the middle of the scrotum. A healthcare provider who is facing a man’s scrotum will grasp the testicle gently and twist in an outward rolling motion (the same motion used when opening a book). This may need to be performed two or three times depending on how twisted the spermatic cord has become. Usually, when the kink has been untwisted, the pain will stop almost immediately. If, for some reason, this “untwisting” procedure is performed at home or away from a healthcare professional’s office, it is still important to see a healthcare provider as quickly as possible. The kinking may return since it is clear the attachment of the testicle to the scrotum is weak. If untwisting is performed at home, the man is often instructed to hold on to the testicle and keep it in position while being transported to a medical facility since the next movement of the scrotum may cause a repeat torsion.
INTERMITTENT (PARTIAL) TESTICULAR TORSION
Although it is less common, a testicle may turn partially rather than turning completely around. Sometimes this is called “partial” or “incomplete” torsion since it twists less than 360 degrees. “Intermittent” refers to the fact that this can occur repeatedly to a man over time. In some cases, the cremaster reflex (the automatic lifting of the scrotum) is still functioning normally.
Case reports of this type of “partial torsion” involve men feeling discomfort in one (or both) of the testicles, but the pain is sometimes not as severe as noted in testicular torsion above. If a man is familiar with the size, shape, and feel of his testicles, he will notice that the soft epididymis that should be on the back of the testicle is located either on the side or even the front. The side of the scrotum that contains the testicle with partial torsion will often be lifted higher than normal in the scrotum, making one side of the scrotum appear “tight” and the other side appear “loose.” For example, when looking in a mirror at the scrotum, the side in partial torsion may be lifted higher and closer to the groin than normal while the other side hangs. The testicle may also be slightly tilted; however, because the twisting is less than in testicular torsion, the testicle may remain upright. Men may also notice that the area above the testicle is more swollen or “full” than the other side that is not twisted.
Like testicular torsion, the testicle will most likely have spun inwards. So, it is best to try to untwist the testicle manually first by spinning it outward. If this is the correct direction, the pain should decrease. If the testicle is twisted in the opposite direction, the pain would get worse, thus indicating the testicle needs to be twisted in the other direction. It’s not uncommon in partial torsion for the testicle to be rotated back beyond “normal” and slightly twist in the other direction. This may require twisting the testicle back in the other direction until the epididymis is facing the rear of the scrotum and the pain is relieved. In some cases, the testicle will spin back almost immediately after being placed back. Lying down or repositioning the body and not allowing the testicles to “hang” can sometimes be of benefit. Like testicular torsion, this type of torsion should prompt a man to seek the opinion of a healthcare professional. Tests such as ultrasounds can be performed to check on blood flow to ensure that no loss of blood or other issues have developed.
Partial torsion may not require surgical correction, but the man should be aware of the feel and position of his testicles and rotate them back into position whenever they are not correct. If this happens repeatedly or for prolonged periods of time, a visit to a healthcare professional to permanently fix the testicle inside the scrotum may be warranted.
TORSION OF THE APPENDIX TESTIS
Rather than torsion or twisting of the spermatic cord, this is the twisting of the appendix testis. The appendix testis is a small tail of tissue – less than ¼ inch long – at the top front of the testicle. The pain usually sets in quickly, but the whole testicle itself isn’t painful. The only portion that is painful is near the top of the testicle where the appendix testis is.
Occasionally, a dark blue/black dot can be seen through the scrotum, but not always. If this dot is seen, it means the appendix testis has had some tissue death and has become gangrenous. The dark dot is the gangrenous tissue being seen through the thin scrotal skin (see illustration below). To see an actual image of the blue dot sign, click HERE.
Although, most of the time, bed rest for five to ten days will help resolve the situation, surgery may be required if the pain is extreme or prolonged, or if the appendix becomes gangrenous. It’s always a good idea to check with a healthcare professional should symptoms associated with torsion of the appendix testis occur.
EPIDIDYMITIS & ORCHITIS
Epididymitis is perhaps one of the most common causes of testicular and scrotal pain. Epididymitis is an inflammation of the epididymis. This can occur for multiple reasons but often begins after a man has strained or lifted something heavy, especially if he had a full bladder. In fact, some men feel some of this pain in their back and mistake their epididymitis as a back issue. There are two types of epididymitis – infectious and non-infectious.
Infectious epididymitis can be caused by some sexually transmitted infections such as chlamydia and gonorrhea (click HERE to learn more). Men with prostate infections can also develop epididymitis. This occurs when bacteria from the prostate migrates from the ejaculatory duct in the prostate, into the ampulla, then down the vas deferens to the epididymis. This migration of bacteria can occur when a man lifts something heavy or strains, thus exerting enough pressure in the pelvis to press infected fluids from the prostatic urethra area down into the vas deferens. In the early stages, the lower portion of the epididymis (the part closest to the vas deferens) is more tender and swollen. This pain and swelling can then migrate up the epididymis (up the back of the testicle) with time.
If the infection moves beyond the epididymis to the testicle, the testicle can become inflamed and painful – this is called orchitis. Most infections of this type are called epididymo-orchitis since the infection affects both the epididymis and the testicle. Either one or both testicles may be involved, but if only one is involved, it is more common for the left testicle to be the one affected since it hangs lower in the scrotum than the right testicle. The pain is often felt as a dull ache rather than a sharp pain. When a healthcare provider checks for the cremaster reflex, the scrotum will contract/lift upwards when the inner thigh is stroked. The rear side of the testicle (where the epididymis is located) will be tender and oftentimes swollen.
Non-infectious epididymitis is not caused by an infection and is usually less severe than infectious forms. This may be caused by urine being pressed down the vas deferens when a man strains or lifts a heavy object. The urine can irritate the sensitive tissues in the epididymis causing inflammation. Another non-infectious cause of epididymitis occurs after a vasectomy (click HERE to learn more). In this case, the epididymis becomes inflamed because there is no exit for the sperm and associated fluids to leave the epididymis after the vas deferens has been blocked (to prevent sperm from moving up to the reproductive glands). This usually resolves itself as the male body begins to resorb excess fluid and sperm. However, in many vasectomies the end of the vas deferens nearest the testicle isn’t clamped off which allows drainage of spermatic fluid.
Treatment is gauged upon the cause. For all types of epididymitis or epidiymo-orchitis, scrotal elevation (lying flat and placing a washcloth under the scrotum to elevate it) can help some of the fluid drain out of the inflamed area and also helps relieve some of the pain. Since the testicles always “hang,” it can be hard for excessive fluid to drain because gravity is working against the fluid to pull it further down into the scrotal/testicular area. Elevating the scrotum allows gravity to work and help “drain” fluids back into the body to be flushed away. Icing the area to prevent swelling can also help (cover the ice bag in a cloth to avoid freezing the area). Over-the-counter anti-inflammatory medications like ibuprofen or naproxen can also be used to decrease inflammation and pain. Finally, supportive underwear (even athletic supporters) can relieve many symptoms. So, men that wear boxers will often need to wear more supportive underwear until the inflammation has passed. If the inflammation is caused by bacteria, antibiotics will need to be prescribed in addition to the above treatment. For this reason, it’s always a good idea to see a healthcare provider to ensure you’re not just treating half of the problem. In some rare and severe cases, surgery may be required to help drain the infection.
A hernia is the protrusion of one organ into a space where it doesn’t belong. It is usually caused by the intestines squeezing into a pocket, space or canal (image at far left). This often occurs near the belly button (image second from left). In the case of an inguinal hernia, part of the intestines can find their way from the abdomen, down into the scrotum through a canal called the inguinal canal – hence the name inguinal hernia. Inguinal hernias can be higher up in the inguinal canal and show as a bulge on the belt line (image on far right) or even descend into the scrotum (image second from the right).
As the testicles are descending from the abdomen into the scrotum right before birth, the testicle descends through the inguinal canal. The right testicle is the last testicle to descend and also the last canal to “close” (that is why the right testicle hangs higher in the scrotum). Because the right side closes last, it is also the side where most inguinal hernias occur. If the canal does not close completely, any pressure in the abdomen can force the contents (usually the small intestine) down the canal and into the scrotum. Also, since the canals close over time, most of these hernias occur in the first year of life; however, they can occur during adulthood if the closure is weak in the canal. When this happens in adults, the abdominal contents in the scrotum can sometimes feel like a “third testicle.” Regarding pain, it is worse in the abdomen than it is in the scrotum.
Inguinal hernias are most often caused by heavy straining – such as having a bowel movement, lifting a heavy object, or lifting weights. They can also be caused by pressure in the abdomen such as when a boy/man sneezes or an infant cries. Hernias can be uncomfortable and painful. Oftentimes, during infancy, treatment simply involves watching and waiting. Surgery may sometimes be required, especially in adulthood. For short term relief, usually while waiting for surgery, a supportive belt called a hernia truss may be used to give support and relief from pain and discomfort. The image below shows a hernia truss worn under the clothing and over the underwear. As you can see, it provides support and protection on the side of the scrotum and around the belt line. However, it is important to understand that hernia trusses do not treat inguinal hernias and should not be used long term as they can make hernias worse. During surgery, the incompletely closed inguinal canal is closed to prevent future hernias.
Hydroceles occur when the sack surrounding the testicle fills with fluid. This is usually not painful when the fluid amount is small and usually causes the scrotum to swell slightly (sometimes leaving few if any wrinkles/folds). However, large amounts of fluid can collect. In some cases, more than a liter (quart) of fluid can accumulate leading to massive swelling of the scrotum (click here to see an example of large hydrocele that has been neglected, click HERE. Hydroceles are often caused by some sort of inflammation like epididymitis or even an injury to the scrotum.
A clinician will often shine a light through the scrotum to help diagnose a hydrocele. In hydroceles, the light will shine through the fluid-filled sack and be visible on the other side of the scrotum. Hydroceles usually aren’t treated unless they are causing pain and pressure, in which case surgery is often the treatment of choice since aspiration (drainage) can often cause the sac to refill with fluid.
IDIOPATHIC SCROTAL SWELLING
This is somewhat similar to a hydrocele, but in this case the scrotum itself fills with fluid rather than the small sack surrounding the testicle. This is more common in children than in adults and is typically painless.
Treatment is fairly easy. Elevating the scrotum (lying flat and placing a washcloth under the scrotum) can help the fluid drain out of the scrotum back into the body. Typically idiopathic scrotal swelling goes away within two days.
Varicoceles occur when the blood vessels in the spermatic cord become varicose veins. The plexus (or network) of blood vessels dilate and fill with blood. This occurs more often on the left side than the right side. These can be felt when a man bears down like he’s about to have a bowel movement. This forces blood into these veins and they swell. This can feel like a “bag of worms” in the scrotum during this bearing down. In some cases, the swollen vessels can be seen pushing out on the scrotum making large ridges on the upper areas of the scrotum above the testicle.
Varicoceles are usually painless, but some aching may occur. The concern with varicoceles is that they can reduce blood flow to the testicle leading to decreased function both in testosterone and sperm production. Oftentimes, varicoceles are discovered when a man is being examined for possible infertility.
Treatment usually consists of over-the-counter anti-inflammatory medications for discomfort and swelling, but sometimes surgery is performed to prevent testicular damage and, in some cases, to increase fertility.
EPIDIDYMAL CYSTS & SPERMATOCELES
Epididymal cysts (also called spermatoceles) are small, firm lumps. They are often smooth, round, and located near the top of the testicle. These are caused by a blockage in the epididymis, thus causing sperm and some fluid to become trapped. These can be concerning when a man is performing a testicular self-exam. They are most often painless and go away on their own.[i]
The size of these cysts can vary and usually they will shrink with time and go away (which is why treatment is often unnecessary). However, they can sometimes be larger. When they are more than about an inch (2.5cm) in size, they are almost always referred to as spermatoceles. Since testicular cancer can also present as lumps, it is a good idea to have these checked out by a healthcare provider.
TESTICULAR TUMORS/TESTICULAR CANCER
Testicular tumors occur most often in young men (teenagers); however, they do occur at any age (but more often in men ages 18-40). Men usually feel tumors as a hard lump that doesn’t feel like fluid. They can occur anywhere on the testicle. If they are located near the top of the epididymis, they can be mistaken for an epididymal cyst. So, it’s always important to have a healthcare provider assess all testicular lumps.
Sometimes testicular tumors can be painful, especially if inflammation has started to set in. Diagnosis of a tumor is performed using an ultrasound and sometimes MRI imaging. Testicular cancer can be life threating if not treated; however, it is perhaps the most treatable type of cancer. Treatment of cancer usually results in removal of the testicle. If a man wishes to have children, sometimes semen is collected and frozen before surgery to allow him and his wife (or future wife) to do intrauterine insemination in the future. Some men may be apprehensive about having a testicle removed and what that will “feel” and “look” like after the surgery. For men that are concerned about this, prosthetic testicles are available that can be placed into the scrotum to give a more natural appearance. However, prosthetic testicles come with pros and cons which a healthcare provider can discuss.
Nearly every guy at some point has been “tagged” or hit in the testicles/scrotum. This is called mild testicular trauma and typically the pain will subside (along with the feelings of nausea) within minutes. Supporting the scrotum can reduce pain (which is why most guys by reflex will cup and hold their scrotum after being kicked in the groin). In the short term, wearing more supportive undergarments (or pulling underwear higher to create more support), along with anti-inflammatory drugs like ibuprofen or naproxen, can help with pain and inflammation for mild trauma.
More severe forms of trauma can cause bleeding in the scrotum. In some cases, injury to the testicle can cause it to bleed. This blood can then fill the space between the testicle and the tissue that surrounds it, causing a hematocele. A hematocele is much like a hydrocele described earlier, except the space is filled with blood instead of clear fluid. When a healthcare provider examines a man with this type of swelling, a light shined through the scrotum will not pass through the blood-filled sac.
In some cases, the testicular trauma can be so severe that the testicle can rupture (almost like a grape being crushed). Testicular rupture typically occurs when the testicle gets pinned against the pelvic bone on one side and a hard surface on the other side. This most often happens in straddling type injuries that leave the testicle with nowhere to “slide.” So, the pressure from the object (saddle, hard bike seat, bar, whatever) and the pelvic bone cause the testicle to “explode” by causing tearing of the outer layer of the testicle. This tearing can cause some of the contents of the testicle, including the seminiferous tubules, to protrude from the testicle. Testicular rupture is a medical emergency and requires surgery.
Trauma to the scrotal and testicular areas can also cause tearing of the scrotal skin. The scrotum has a large blood supply, so this can lead to a lot of bleeding. Medical attention should be sought for severe tears in the scrotal skin. However, the skin of the scrotum often heals very well.
OTHER CAUSES OF TESTICULAR/SCROTAL PAIN
Some causes of testicular and/or scrotal pain and discomfort can be caused elsewhere in the body, but “felt” in the scrotal area. The nerves from the scrotum connect to the pelvic plexus nerve network. This plexus also has nerves coming from other reproductive structures. Infections and inflammation in the prostate can radiate pain into the scrotum. Sometimes, the first sign of prostatitis involves “sore” testicles. To learn more about prostatitis, click HERE.
Some medications can also cause testicular pain and discomfort. Medications that affect testosterone production are often a culprit. 5-alpha reductase inhibitors (finasteride and dutasteride) block testosterone from turning into DHT and cause scrotal/testicular discomfort, especially at higher doses. In some cases, lowering the dose or slowly increasing the dose can relieve this pain. In addition, testosterone replacement, erectile dysfunction drugs like alprostadil, and other medications such as antidepressants, can sometimes cause testicular pain.
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