Scrotal Pain (Acute, Non-Traumatic)

Population Covered By The Guidance

This pathway provides guidance for the imaging investigation of male patients with non-traumatic acute scrotal pain.

Lead Researcher: Dr Sian Chin

Experts & Contributors: Dr James Anderson, Dr Ravinder Dhillon, Prof Dickon Hayne, Dr Julian Mander, Dr Martin Marshall

Date reviewed: April 2018

Date Published: June 2018; Limited revision August 2026, Clin Prof Richard Mendelson

Image 1 (Ultrasound): Swelling of the right epididymis with associated mild orchitis. Doppler images (not shown here) demonstrate increased vascularity.

Epididymo-Orchitis

Image 2 (Ultrasound): Solid and cystic lesion with thick walls and marked vascularity in some areas. The appearances are consistent with a tumour.

Testicular Tumour

Image 3a: Orchidectomy specimen showing complete replacement of the normal testicular parenchyma with the classical

Testicular Tumour

Image 3b (H&E, x2.5): Histological section of a seminoma showing groups of malignant cells with large nuclei and prominent nucleoli. There are also intervening fibrous bands with an infiltrate of lymphocytes and plasma cells.

Testicular Tumour

Image 4a (H&E, x2.5): Orchidectomy specimen showing a teratoma with areas of cyst formation and haemorrhage.

Testicular Tumour

Image 4b (H&E, x2.5): Histological section of a teratoma (non-seminomatous germ cell tumour) showing hyaline cartilage and islands of columnar epithelium.

Testicular Tumour

  • There are many causes of acute scrotal pain. Torsion of the testis, epididymo-orchitis and torsion of the testicular appendage are the most common
  • If torsion is suspected following history and physical examination, imaging should not delay urgent surgical exploration
    • The viability of a torted testicle declines significantly with time, up to 100% salvageable within 6 hours, but almost none are salvageable at 24 hours
    • Negative surgical exploration is preferable to a missed diagnosis because all imaging studies have a false negative rate
  • Epididymo-orchitis is the most common cause of scrotal pain in adolescents and adults and is diagnosed clinically. Ultrasound is indicated if there is concern about a scrotal abscess or after failure to respond to treatment
  • Doppler ultrasound is only indicated in equivocal cases or where there is a low suspicion for torsion on clinical evaluation. Other causes for scrotal pain can also be demonstrated on ultrasound

References

  1. Davenport M. ABC of general surgery in children. Acute problems of the scrotum. BMJ : British Medical Journal. 1996;312(7028):435-7. (Level II evidence).
  2. Dunne PJ, O'Loughlin BS. Testicular torsion: time is the enemy. Aust N Z J Surg. 2000;70(6):441-2. (Level II evidence).
  3. Makela E, Lahdes-Vasama T, Rajakorpi H, Wikstrom S. A 19-year review of paediatric patients with acute scrotum. Scand J Surg. 2007;96(1):62-6. (Level II evidence).
  4. Tekgül S, Dogan HS, R. Kocvara, Nijman JM, Radmayr C, Stein R, et al. EAU guideline on paediatric urology. European Association of Urology. 2017 (Guideline).
  5. Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105(3 Pt 1):604-7. (Level II evidence).
  6. Bowlin PR, Gatti JM, Murphy JP. Pediatric testicular torsion. Surg Clin North Am. 2017;97(1):161-72. (Review article).
  7. Al Shakarchi J, Bowley D, Hendrickse C. Guidelines for the management of acute scrotal pain in children. Heart of England NHS Foundation Trust. 2011.
  8. Kaplan G. Testicular torsion. BMJ Best Practice; 2018. (Review article).
  9. Hartman MS, Leyendecker JR, Friedman B, Fulgham PF, Heller MT, Hosseinzadeh K, et al. Acute onset of scrotal pain - without trauma, without antecedent mass. American College of Radiology ACR Appropriateness Criteria. 2014 (Guideline).
  10. National Institute for Health and Care Excellence. Management of paediatric torsion. 2015. (Guideline).
  11. Murphy FL, Fletcher L, Pease P. Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum. Pediatr Surg Int. 2006;22(5):413-6. (Level II evidence).
  12. Lopez RN, Beasley SW. Testicular torsion: potential pitfalls in its diagnosis and management. J Paediatr Child Health. 2012;48(2):E30-2. (Review article).
  13. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-40. (Review article).
  14. Wilbert DM, Schaerfe CW, Stern WD, Strohmaier WL, Bichler KH. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol. 1993;149(6):1475-7. (Level II evidence).
  15. Suzer O, Ozcan H, Kupeli S, Gheiler EL. Color Doppler imaging in the diagnosis of the acute scrotum. Eur Urol. 1997;32(4):457-61. (Level II evidence).
  16. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology. 1990;175(3):815-21. (Level III evidence).
  17. Altinkilic B, Pilatz A, Weidner W. Detection of normal intratesticular perfusion using color coded duplex sonography obviates need for scrotal exploration in patients with suspected testicular torsion. J Urol. 2013;189(5):1853-8. (Level II evidence).
  18. Horstman WG, Middleton WD, Melson GL. Scrotal inflammatory disease: color Doppler US findings. Radiology. 1991;179(1):55-9. (Level II-III evidence).
  19. Guthrie JA, Fowler RC. Ultrasound diagnosis of testicular tumours presenting as epididymal disease. Clin Radiol. 1992;46(6):397-400. (Level II evidence).
  20. Allen TD, Elder JS. Shortcomings of color Doppler sonography in the diagnosis of testicular torsion. J Urol. 1995;154(4):1508-10. (Level IV evidence).
  21. De Zordo T et al. Multiparametric ultrasonography of the testicles. Nat Rev Urol. 2013;10(3):135-48.
  22. Bertolotto M et al. EFSUMB Guidelines on Multiparametric Ultrasound of the Scrotum. Ultraschal Med. 2026. https://www.thieme-connect.de/products/ejournals/pdf/10.1055/a-2785-3267.pdf
  23. Sweet D et al. Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. Abdom Radiol (NY). 2020;45(7):2063-2081.
  24. Gerena M et al. ACR Appropriateness Criteria® Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass: 2024 Update. J Am Coll Radiol. 2024;21(11S):S364-S371.
  25. Bertolotto M et al. Multiparametric US for scrotal diseases. Abdom Radiol (NY). 2018;43(4):899-917.

Pathway User Guide

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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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