Testicular pain is one of the most common urological complaints in men. Pain can be in only one testicle or in both testicles. These pains may not always originate directly from the testis, but may sometimes occur due to the disease of neighboring organs or a distant organ. Patients with testicular pain often come to the doctor late because they are embarrassed.

The pain can occur suddenly or it can be long lasting. Most importantly, testicular pain can also be a symptom of an emergency disease such as testicular torsion. In fact, pain is not a disease by itself, but a symptom, that is, a symptom of a disease. In this article, I will talk about testicular pain, which is a symptom.

What is testicular pain?

Testicular pain is the pain that occurs due to diseases such as trauma, infection (orchitis), tosion and tumor of the testis. Testicular pain is not a disease, it is a symptom of many diseases.

It is possible to classify the causes of testicular pain in 3 groups according to the origin and duration of the pain.

• Acute testicular pain: This type of pain occurs suddenly. It is usually seen in diseases such as trauma, infection (orchitis) and testicular torsion.
• Chronic testicular pain (Orchialgia): If testicular pain is present for more than 3 months, then chronic testicular pain is mentioned. It is usually the pain in the testicles due to long-term diseases such as chronic prostatitis and chronic epididymitis. Chronic testicular pain is called orchialgia.
• Referred pains: These pains are not directly caused by a disease in the testis. It is seen due to diseases in other organs. It is usually seen as the reflection of ureteral stones to the testicles.

What are the causes of testicular pain?

Testicular pain is not just caused by the disease of the testis itself. As a result of the discomfort of many organs, pain can be felt in the testis. This pain can be unilateral or can be seen in both testicles. Testicles are found to be normal in examinations and tests for pain not originating from the testis. Causes of testicular pain include:

• Testicular trauma: Testicular trauma usually causes acute testicular pain. Traumas Trauma can be seen in the form of blunt traumas, penetrating and cutting injuries. Traumas with penetrating and cutting injuries are urgent and a urologist must be consulted. In injuries, sometimes the testicular parenchyma is not affected, only edema and hematoma occur in the skin and subcutaneous tissues. Sometimes, in severe traumas, the internal structure of the testis is also affected and the testis can be fragmented. In these cases, urgent surgical intervention is required. In mild traumas, pain relievers, bed rest and cold application are sufficient.
• Orchitis: Orchitis is an inflammatory disease of the testis. Pain and swelling in the testis are common complaints. Bleeding can be seen in semen and urine. It is mostly due to bacterial infections. Orchitis due to mumps virus (mump virus) can be seen in adolescence. Appropriate antibiotic therapy should be initiated in the treatment of orchitis due to bacterial causes. In addition, anti-inflammatory drugs, bed rest and cold application relax the patients.
• Inguinal hernia (inguinal hernia): Normally, there is no pain in small hernias. If the inguinal hernia is large and goes down to the scrotum and there are intestines in it, sometimes the hernia sac does not return to its original state and there is pain. In these cases, there is a risk of suffocation and damage to the intestinal parts in the hernia and urgent surgery is required.
• Epididymitis: It is the inflammation of the semen ducts called the epididymis. On examination, the epididymis is painfully swollen. In cases of chronic epididymitis, the epididymis is hard. Usually, the testicles are normal on examination, but because the epididymis is adjacent to the testis, pain can also be felt in the testis. In acute cases, the pain is more severe. Generally, patients are relieved at rest. Antibiotics, anti-inflammatory drugs and rest are recommended for treatment. In acute cases, bed rest, scrotal elevation and application of ice relieve the patients. Sexually transmitted diseases in sexually active age are gonorrhea and chlamydia. Bacterial infections are common in the elderly.
• Epididymal hypertension (Blue balls): This is more common in patients with excessive sexual arousal but no ejaculation. It is common in young men of sexually active age. The pain is not very severe. Usually, a blunt pain is felt in the form of pressure and fullness in the testicles. Very rarely, there may be slight blueness in the testicles. It is not a serious condition, the pain is relieved after ejaculation. Sometimes it goes away on its own after hours.
• Spermatocele: Spermatocele are cystic structures formed in the head of the epididymis and filled with sperm. If it grows too large and causes pain, it must be surgically removed.
• Hydrocele: Hydrocele is the collection of fluid between the inner and outer leaf of the tunica vaginalis surrounding the testis. It can cause varying degrees of pain in the testis. The treatment is surgery.
• Varicocele: Varicocele is the enlargement of the veins of the testis, that is, its varicose veins. It is usually seen in the spleen, very rarely in both testicles. Pain may be more frequent in patients with high-grade varicocele. It is usually felt as a result of standing for a long time. The definitive treatment is surgery.
• Testicular torsion: Testicular torsion is a condition that occurs as a result of the rotation of the structure called the cord, which contains the arteries and veins of the testis, around itself. Severe pain, nausea and vomiting are seen in the testicles and towards the abdomen. The pain does not go away with rest. Pain increases with raising the testis manually (Phrene’s sign). However, in epididymitis and orchitis, the pain decreases with rest and raising the testis. As a result of this rotation, the testicular artery is occluded and the feeding of the testis is disrupted, eventually loss of function in the testis. It is common during adolescence. It’s an emergency. It must be treated with surgical intervention.
• Urinary system stones: Ureteral stones cause colic pain by blocking the ureteral canal. Sometimes these pains hit the testicles in men according to the location of the stone. These pains are referred to as percussive or referred pains. In the examinations, there is no disease in the testis itself.
• Post vasectomy: It is the testicular pain seen in patients whose semen ducts are tied (vasectomy) for birth control. In some patients, swelling and pain occur as a result of excessive accumulation of semen in the epididymis. This is called congestive epididymitis. Sometimes, because the sperm cannot be expelled, they accumulate in the testicles and small painful nodules called “sperm granulomas” form. If the nerve is tied and compressed during vasectomy, a condition called “post vasectomy pain syndrome” may be seen rarely.
• Testicular cancer: Testicular cancer usually does not have testicular pain. The most important finding of testicular cancer is the palpation of a painless and hard mass in the testis on examination. If bleeding into the mass or infarction occurs, there may be pain.
• Idiopathic pain: Sometimes, there may be chronic pain in the testicles for which no cause can be identified. These pains can disturb patients psychologically. Usually idiopathic pains are blunt and mild.
• Sexually transmitted diseases: In sexually transmitted infections, testicles and epididymis may be involved and cause testicular pain.
• Prostatitis: Pain in both testicles and groin is seen in patients with chronic prostatitis. These pains increase especially in cold weather. It is in the form of blunt and constant pains.
• Scrotal diseases: Diseases of the non-testicular organs in the scrotum can cause testicular pain.
• Disc herniation pains: Rarely, disc herniation pains may be reflected to the testis. Disc pain can be distinguished by examination and other radiological tests.
• Digestive system diseases: Digestive system diseases can cause nausea, vomiting and testicular pain. Testicles are found to be normal in the examinations.
• Diabetic neuropathy: Sinus damage occurs in diabetic patients for a long time and in uncontrolled patients. This condition is called “diabetic neuropathy”. These patients may also have testicular pain if the nerves in the spermatic cord are affected.
• Referred pain: Not every pain seen in testicles is directly related to testicular disease. Sometimes organ pains that develop from the same area of ​​nerves also hit the testicles. These pains are called “reflected pains”. This is common in ureteral colchicles.
• Fournier’s gangrene: Fournier’s gangrene is the gangrene of the skin and subcutaneous tissues starting from the scrotal, perineal region and extending to the lower parts of the abdomen. It is usually seen in diabetic patients. The testicles are usually not involved. Its treatment is immediate removal of necrotic tissues.

What are the other symptoms that can be seen with testicular pain?

Patients with testicular pain may sometimes have complaints other than pain. These complaints are usually urinary system and gastrointestinal system complaints. Other symptoms (complaints) accompanying testicular pain are:

• Scrotal trauma scar
• Nausea and vomiting
• Swelling in the scrotum (edema)
• Fever
• Complaints about urination

How is testicular pain diagnosed?

A systematic approach is required for patients presenting with testicular pain. Patients are evaluated urologically in detail. Other system diseases that may cause testicular pain are investigated. The procedures to be performed for diagnosis are as follows;

• History. Detailed medical questioning of the patient
• Physical examination: Urological and general examination
• Urine tests
• Blood tests
• Scrotal USG
• CT, MR

How to protect against testicular pain?

Testicular pain occurs after the testicles and some other organs. It is possible to protect against testicular diseases. For this purpose, we recommend our patients to pay attention to the following points;

• Using athletic clothing to protect the testicles
• Protection during intercourse
• Examining your own testicles
• Vaccinating children against mumps

Treatment of testicular pain

Testicular pain is not a disease, but a symptom of more than one disease. Therefore, in order to treat pain, it is necessary to first reveal the cause. The treatment is started after the pain test is determined correctly. We examine the treatment of testicular pain in two main groups;

Non-surgical treatment methods: Here, patients are treated conservatively and, if there is an infection, antibiotic treatment. Non-surgical treatment methods include;

• Cold application
• Scrotal elevation
• Bed rest
• •Painkiller
• Antibiotic
• Antidepressant

Surgical treatment methods: If testicular pain does not go away with non-surgical methods, if patients complain of pain and if the disease can only be treated with surgery, we recommend these patients to undergo surgery. Especially if there is testicular cancer and testicular torsion, surgery must be performed. Surgical treatment methods vary according to the underlying disease. These methods are:

• Correction of testicular torsion
• Hernia surgery
• Epididymectomy
• Reanastomosis if vasectomy was performed
• ESWL
• URS
• Spermatic cord microdenervation
• Orchiectomy
• Radical orchiectomy

Home treatment for testicular pain

In a patient with testicular pain, if there is no need for emergency intervention, some comforting measures can be taken at home. If there is a sore throat, high fever, nausea and vomiting, and very severe pain, patients should definitely go to a urology specialist. Some comforting measures that patients can do at home are:

• Bed rest
• Keeping the testicles up
• Application of cold (ice)
• Taking painkillers

When to go to Urologist if there is testicular pain?

In mild and chronic testicular pain, patients usually do not go to the doctor. In these cases, some relaxing (conservative) treatment methods may be effective. However, in some cases, we recommend our patients to go to a urology specialist. These situations are:

• If there is swelling, redness, high fever, nausea and vomiting in the scrotum
• If there is sudden onset of severe pain: If there is a sudden onset of severe pain and the pain does not go away with rest, testicular torsion should be suspected. Plant torsion occurs at any age, but is more common during adolescence. This situation is urgent, testicular functions are lost if not intervened in time. A urologist must be consulted.
• If there are penetrating and cutting tool injuries
• If there is a hard mass in the testis

Does testicular cancer cause testicular pain?

Testicular cancer very rarely causes pain in the testis. The most important finding of testicular cancer is the formation of a painless stiffness in the testis. In this way, if there is painless stiffness in the testis, ultrasonography and testicular tumor markers (AFP, beta HCG, LDH) should be checked. Since there is no pain, these patients come to the doctor late. In the following cases, testicular pain occurs in testicular cancer;

• If bleeding into the tumor occurs
• If there is torsion

In summary; Testicular pain can be a symptom of diseases originating from the testes, or it can be seen as a symptom of other organ diseases hitting the testicle. It is a common urological problem in men. Testicular cancer typically does not cause pain in the testis, the most important symptom being a painless hard mass in the testis. Sometimes it can be a symptom of an emergency disease such as testicular torsion, and in this case, urgent surgical intervention is required. Chronic testicular pain may persist for a long time in patients and this may negatively affect the daily lives of patients. There is no single treatment for testicular pain.

The exact treatment depends on the cause. First of all, the cause of the pain should be determined and specific treatment should be given accordingly. Treatment options vary depending on the cause. Often, outpatient treatment and bed rest are effective. Sometimes surgery may be the only option.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul – TURKIYE