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Failure to diagnose the surgical condition of testicular torsion is a relatively common source of claims against GPs.


Scrotal pain in males can occur in all age groups but the child or adolescent with acute scrotal pain often poses a diagnostic challenge. Serious problems include testicular torsion, strangulation of an inguinoscrotal hernia, a testicular tumour and a haematocele, all of which require surgical intervention.

Key facts and checkpoints

  • Torsion of the testis is not the most common cause of acute scrotal pain in childhood and adolescence, but it is the most important.1

  • Torsion is most common in males younger than 25 years.

  • Testicular pain can be referred to the abdomen.

  • Torsion should form part of the differential diagnosis in a boy or young man who is vomiting and has intense pain in the lower abdomen inguinal region.

  • The loss of a testicle from torsion, an avoidable problem, is a real ‘time bomb’ and a common reason for litigation for medical negligence.

  • The clinical picture of epididymo-orchitis can mimic torsion so closely that in many boys and young men the diagnosis should be made only at surgical exploration.1

  • An abnormality predisposing to torsion is usually present bilaterally; the opposite testis should also be fixed to prevent torsion (orchidopexy).

  • Torsion must be corrected as soon as possible to reduce the chance of gangrene and loss of the testis.

  • Suspect self-correcting testicular torsion in repeated episodes of severe spontaneously resolving pain. Refer for possible orchidopexy.

  • Suspect abscess formation if epididymo-orchitis does not settle with a reasonable course of antibiotics. Surgical drainage may be necessary.

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



It is important to determine whether there were any pre-existing predisposing factors or history of trauma.

Key questions

  • Have you noticed any burning of urine or penile discharge?

  • Have you had an injury to your scrotal region such as being struck by a ball or falling astride something?

  • Have you travelled overseas recently?

  • Have you been aware of a lump in your testicle or groin?

  • Have you had an illness lately and have you noticed swelling of the glands in your neck or near your ear (i.e. screening for mumps)?

  • Do you have back pain or have you injured your back?


Examine and compare both sides of the scrotum. Inguinal and femoral hernial orifices, the spermatic cord, testis and epididymis must be checked on both sides. The size, lie and elevation in the scrotum of the testis should be assessed, as should the cremasteric reflex. This is done by stroking or pinching the medial thigh, and considered positive if the testicle moves at least 0.5 cm. An absence of the ...

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