Acute scrotal pain or swelling

PIC Endorsed

Key points

Testicular torsion and irreducible hernia are emergencies and if suspected, require urgent surgical evaluation
Ultrasound should only be considered in selected cases of testicular pain, after surgical assessment, to avoid delays in management
Scrotal trauma/bruising, especially in infants or where the causal mechanism is unclear, should prompt the clinician to consider child abuse

Background

The most common causes of acute scrotal pain and/or swelling are torsion of the testicular appendage (appendix testis), epididymitis and testicular torsion
Delays in surgical management of testicular torsion result in higher rates of testicular loss. Torsion within 4 to 6 hours: 80 to 100 percent viability
Although viability is low with delayed presentations, urgent surgical opinion should still be sought

Assessment

Scrotal pain +/- swelling

	Testicular torsion	Irreducible hernia	Torsion of testicular appendage	Epididymo-orchitis	Trauma eg testicular or epididymal rupture
Typical age group	Pubertal (and rarely neonates)	Infants	Pre-pubertal (7-12 years)	<2 years and post-pubertal (rarely pre-pubertal)	Any age
Pain	Severe Usually sudden onset May radiate to iliac fossa or thigh May be painless in neonates	Irritable	Usually sudden onset Usually minimal at rest	Sudden or subacute onset May improve with elevation	May be delayed
Swelling	Yes	Yes May extend to scrotum (cannot get above the scrotal swelling)	Yes	Yes	May be delayed
Fever	Unusual	Unusual	Unusual	Common	Unusual
Nausea and vomiting	Common (90%)	Common	Uncommon	Uncommon	Uncommon
Dysuria or discharge	No	No	No	Common	No
Gait	Impaired	-	May be impaired	-	May be impaired
Position of testis	May be high riding or horizontal	-	Normal	-	-
Palpation	Tender Thickened spermatic cord	Firm and tender Swelling not reducible	Focal tenderness of upper pole of testis	Tender postero-lateral testis	Tender
Oedema crosses midline	No	No	No	Possible	Possible
Discolouration	Red/blue Dark in neonate	-	Blue dot sign	Red	Bruising (consider causes eg child abuse)
Cremasteric reflex	Usually absent	Usually present	Usually present	Usually present	Usually present
Reactive hydrocele	Possible	No	No	Possible	Possible

Other causes of testicular pain

Pain may be referred to the testes from other sites, including
- intraabdominal: appendicitis/renal colic/UTI
- referred hip pain
Skin infections of the scrotum
- cellulitis/shingles
Testicular pain and swelling can occur in Henoch-Schönlein purpura secondary to vasculitis in the scrotum

Non-painful scrotal swelling

	Hydrocele	Varicocele	Idiopathic scrotal oedema	Tumour/leukaemia
Typical age group	Infants	Peri-pubertal	3-7 years	1-8 years
Fever	Unusual	Unusual	Unusual	Possible
Palpation	Soft Non-tender Fluctuant	"Bag of Worms" Occasionally tender Larger with time standing, may reduce on lying	Non-tender May have low-grade discomfort	Hard Non-tender May be painful if rapidly growing
Swelling pattern	Scrotal, can get above the swelling	Predominantly left-sided	Can extend across midline and into perineum, groin, penis	Unilateral or bilateral
Discolouration	No	No	Purplish, erythema (may extend into perineum, groin or thigh)	No
Transilluminable	Brightly	No	Oedema can give illusion of transillumination	No
Reactive hydrocele	-	No	Possible, resolves with oedema	Possible

Management

Investigations

Surgical review should not be delayed in the interest of investigations
Blood tests, ultrasound and doppler ultrasound are not useful in the acute setting (excluding traumatic injuries)
- Although ultrasound has the capacity to assess the structure and vascularity of the testes without exposure to radiation, findings may not be specific to torsion and negative ultrasound has been documented in cases of torsion
- May also cause delay to definitive surgical management, affecting the viability of the testis
Once testicular torsion and irreducible hernia have been excluded, ultrasound may be considered if the diagnosis remains unclear
- Colour doppler flow ultrasound may assess blood flow, anatomy and may localise swelling and fluid collections
Consider urinalysis (nephrotic syndrome) and urine MCS

For suspected epididymo-orchitis

Urine MCS (ideally first pass urine collection)
- Bacterial infection more likely in child with structural urinary tract abnormalities, recent instrumentation of urinary tract, or STI
- A normal urine does not exclude epididymo-orchitis
Urine Chlamydia and Gonorrhoea PCR testing (if STI clinically suspected)
Viral causes include enterovirus, adenovirus and rarely mumps (mumps orchitis occurs 4-6 days after parotitis). If mumps is suspected: RT-PCR and/or IgM

Treatment

Diagnosis	Management
Testicular torsion	If suspected, or cannot be confidently excluded, urgent surgical review Fast (nil by mouth or sips of clear fluid per local guideline) until surgical review Provide adequate analgesia
Irreducible hernia	If unable to reduce, urgent surgical review Fast (nil by mouth or sips of clear fluid per local guideline) until surgical review Consider a nasogastric tube on free drainage if bowel obstruction is suspected Provide adequate analgesia
Torsion of testicular appendage	May be difficult to distinguish from testicular torsion Requires surgical exploration if unable to confidently exclude testicular torsion Once diagnosis confirmed, treatment is supportive, with analgesia and rest Pain should resolve in 5-10 days
Trauma	Surgical review for all testicular trauma, unless the testis is clearly felt to be normal and without significant tenderness In cases of suspected child abuse presenting with testicular or scrotal trauma, see Child abuse
Suspected epididymo-orchitis	Antibiotics: IV if systemically unwell/young infant, oral if well Second episode: renal tract ultrasound and urological review May have weeks of gradually subsiding scrotal discomfort and swelling
Hydrocele	90% resolve spontaneously by 2 years Consider outpatient surgical referral for repair if present after 2 years of age
Varicocele	Refer to surgical outpatients
Scrotal oedema	Scrotal oedema can occur in setting of systemic disease eg nephrotic syndrome If idiopathic, resolves spontaneously over 1-5 days. No intervention required

Consider consultation with local surgical team

in all cases where testicular torsion cannot be confidently excluded (urgently)

Consider consultation with local paediatric team

in cases of suspected child abuse, see Child abuse

Consider transfer when

Surgical management unavailable at local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Surgical advice has been provided
Follow up plan in place and review scheduled (if required)

Parent information

Inguinal hernia
Abdominal pain
Testicle injuries and conditions

Last updated January 2026

Reference List

Brenner, J et al. Causes of painless scrotal swelling in children and adolescents. Retrieved from https://www.uptodate.com/contents/causes-of-painless-scrotal-swelling-in-children-and-adolescents (viewed May 2020)

Brenner, J et al. Causes of scrotal pain in children and adolescents. Retrieved from https://www.uptodate.com/contents/causes-of-scrotal-pain-in-children-and-adolescents(viewed May 2020)

Brenner, J et al. Evaluation of nontraumatic scrotal pain or swelling in children and adolescents. Retrieved from https://www.uptodate.com/contents/evaluation-of-nontraumatic-scrotal-pain-or-swelling-in-children-and-adolescents(viewed May 2020)

Children’s Health Queensland Hospital and Health Service, Acute scrotal pain – Emergency management in children. Retrieved from https://www.childrens.health.qld.gov.au/guideline-acute-scrotal-pain-emergency-management-in-children/ (viewed May 2020)

McBride, C et al 2017, Acutely painful scrotum: Tips, traps, tricks and truths, J Paediatr Child Health, 53:1054-1059.

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines