Testicular Pain

Lots of things can cause painful testicles. There are 2 main causes but it can be hard to tell which it is — always do medical consult for testicular problems

Testicular torsion — twisted testis/testicle is a medical emergency — can cause necrosis (testicle tissue can die)

If you can’t exclude twisted testicle — send to hospital urgently

Epididymo-orchitis — infected testes

In children — usually due to UTI or viruses but may be STI in sexually active boys — consider sexual abuse
In younger men — usually due to STI
In older men or men with recent urinary tract procedure or catheter — may be due to UTI bacteria
Can be due to mumps virus
Decision to manage as infected testes is based on clinical assessment regardless of POC Test or laboratory results

Red Flags — Urgent Medical Consult
Testicular torsion (twisted testicle) Epididymo-orchitis (infected testes) in children Painless swelling of scrotum — could be cancer

Check

Calculate age-appropriate REWS

Adult — AVPU, RR, O₂ sats, pulse, BP, Temp
Child (less than 13 years) — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp

Weight, BGL

U/A
Head-to-toe exam — with attention to

Abdominal assessment —consider hernia
Scrotum and testes — Table 7.34

Full STI check

If under 15 years — medical consult

Table 7.34 Assessing painful testes

	Testicular torsion (twisted testicle)	Epididymo-orchitis (infected testes)
Age	Any age including infants less than 2 years Most common 12–18 years	Any age — less than 2 years and post-pubertal are peak ages Unusual between 2–14 years
How it started	Usually starts suddenly — few seconds or minutes but can start more slowly	Usually starts gradually — over several hours or days
Pain	Always painful — can be severe If pain stops in 4–6 hours — testicle may be dying, not getting better	Usually mild to moderate pain
Temp	Usually less than 37.5°C	May be over 37.5°C
Scrotum	Only one testicle involved Very tender, hot, swollen Testicle often higher, lying on its side — examine man standing up	One or both testicles involved Tender, hot, swollen
When you lift testicle	Pain may get worse	Pain may get better
U/A	Usually normal	Almost always leucocytes and/or blood and/or protein
Other problems or symptoms	Nausea, vomiting Sometimes lower abdominal pain	Discharge from penis Dysuria (pain when passing urine) May be lower abdominal pain

Do — if twisted testicle

Do not let him eat or drink anything — may need operation — consider IV fluids
Give pain relief — usually moderate–severe pain
Urgent medical consult to send to hospital

Do — if infected testes

Give pain relief
Advise wearing firm underpants — may help pain
Medical consult

All men with discharge from penis AND men under 45 years with no discharge

Treat as STI related

Give ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
AND azithromycin oral — adult 1g, single dose
THEN doxycycline oral — adult 100mg, twice a day (bd) for 14 days OR azithromycin oral — adult 1g, single dose — second dose 1 week later
If allergy to penicillin — medical consult

Men 45 years or over with no discharge

Treat as UTI related

Follow-up

Tell man to come back straight away if getting worse
If likely to be STI related — offer STI check and treatment to sexual partner/s

At 3 days

Check results of STI check and urine MC&S if available

If results show different infection — medical consult about changing antibiotic
If positive STI result — contact trace and treat partners for gonorrhoea and chlamydia
STI and safer sex education
If UTI — see UTI follow-up

If not getting better — medical consult to send to hospital
If getting better — continue antibiotics and review at 1 week

At 1 week

Check results if not available earlier — follow-up as above
Check antibiotics taken properly
If using azithromycin OR if all doxycycline not taken — give azithromycin oral — adult 1g, single dose