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Probability diagnosis

Trauma including haematoma, haematocele

Torsion of a testicular appendage



Post vasectomy

Serious disorders not to be missed


  • testicular torsion


  • acute epididymo-orchitis/orchitis

  • fulminating necrotising cellulitis (Fournier’s gangrene)

  • psoas abscess

  • tuberculosis


  • testicular neoplasm


  • strangulated inguinoscrotal hernia

  • acute hydrocele

Pitfalls (often missed)

Referred pain (e.g. spine, ureteric colic, abdominal aorta)


  • idiopathic scrotal oedema

  • polyarteritis nodosa

  • filariasis

Key history

Determine any pre-existing predisposing factors such as lumps or history of trauma. Check travel history, sexual history.

Key examination

  • Examine and contrast both sides of the scrotum, including the inguinal and femoral hernial orifices, the spermatic cord, testis and epididymis

  • Examine the patient standing and supine

  • A painful testis should be elevated gently to determine if the pain improves

Key investigations

Useful investigations include:

  • FBE

  • urine analysis, microscopy and culture

  • Chlamydia detection tests

  • ultrasound

  • technetium-99m scan.

Diagnostic tips

  • Torsion of the testis is the most common cause of acute scrotal pain in infancy and childhood.

  • Think of it with lower abdominal pain and/or vomiting.

  • A varicocele can cause testicular discomfort—examine the patient in the standing position.

Red flags:

  • sudden onset pain

  • non-reductible hernia

  • erythema of scrotum or perineum

  • systemic vascular symptoms, e.g. hypotension, pallor.

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