Pain in the Testicles

Sudden testicle pain: rule out torsion

In testicular torsion, the testicle rotates on its spermatic cord, cutting off its blood supply. The testicle can usually be saved if surgery happens within about 6 hours, and the chance drops sharply after 12 hours.

Typical features:

• sudden, severe pain in one testicle, often waking someone from sleep or after exercise
• nausea and vomiting
• a swollen, very tender testicle that may sit higher than the other or lie horizontally
• absent cremasteric reflex (stroking the inner thigh normally makes the testicle rise)
• previous brief episodes of similar pain that resolved (intermittent torsion)

Teenage boys sometimes feel only lower abdominal pain and may be embarrassed to mention their testicles. Any boy with sudden abdominal or groin pain should have his testicles checked.

Torsion of a testicular appendage (a small tissue remnant) causes similar but usually milder pain in boys aged 7 to 14, sometimes with a tender "blue dot" at the top of the testicle. It settles with rest and pain relief.

Common causes of testicle pain

Epididymitis and orchitis

Epididymitis is inflammation of the coiled tube at the back of the testicle. Pain and swelling build over hours to days, often with fever, burning urine or discharge. In sexually active men under 35, chlamydia and gonorrhea are the usual causes. In older men, urinary bacteria are more common, often with prostate enlargement. Orchitis is inflammation of the testicle itself, often with epididymitis, or from mumps.

Lifting the testicle sometimes eases pain in epididymitis but not in torsion, though this sign is not reliable enough to exclude torsion.

Injury

A blow to the testicles causes immediate severe pain and nausea that usually fades within an hour. Ongoing pain, swelling or bruising needs an ultrasound to check for rupture, which needs surgery.

Inguinal hernia

An inguinal hernia is a bulge of intestine or fat through the groin wall, which can extend into the scrotum. It causes a dragging ache that worsens with lifting or coughing. A hernia that becomes hard, painful and will not go back in can be strangulated, an emergency.

Kidney stones

A kidney stone passing down the ureter causes severe waves of pain in the side or back that spread into the groin and testicle. The testicle itself looks and feels normal.

Varicocele

A varicocele is a cluster of enlarged veins, usually above the left testicle, that feels like a "bag of worms". It causes a dull ache or heaviness, worse after standing or exercise, better lying down. It can affect fertility.

Other causes

• Hydrocele and spermatocele: fluid collections that cause swelling and heaviness more than pain.
• Post-vasectomy pain syndrome: ongoing aching after vasectomy in a small proportion of men.
• Referred pain: from the lower back (nerve irritation), hip, or prostate.
• Chronic orchialgia: testicle pain lasting more than 3 months, often without a clear cause, sometimes linked to nerve irritation or pelvic floor tension.
• Testicular cancer: usually a painless lump or heaviness, but about 1 in 10 present with pain.
• Fournier's gangrene: rare, rapidly spreading infection of the genital skin, mainly in people with diabetes.

Left vs right testicle pain

How doctors find the cause

A doctor will ask when and how the pain started, whether it was sudden, and about vomiting, fever, urinary symptoms, sexual history, injury and previous episodes. They will examine the scrotum and groin, standing and lying, and check the cremasteric reflex.

Tests include:

• Urine test and swabs or urine tests for chlamydia and gonorrhea
• Doppler ultrasound to check blood flow to the testicle and look for lumps, fluid and varicoceles
• CT scan if a kidney stone is suspected

If torsion is strongly suspected, surgeons may operate straight away without waiting for a scan.

Treatment

• Torsion: emergency surgery to untwist and fix the testicle, and usually fix the other one too. A testicle that has died must be removed.
• Epididymitis: antibiotics chosen according to the likely germ, rest, scrotal support, ice and pain relief. Sexual partners need testing and treatment if an STI is the cause.
• Hernia: surgical repair; emergency surgery if strangulated.
• Kidney stones: pain relief, fluids, and procedures for large stones.
• Varicocele: supportive underwear; surgery or embolization for pain or fertility issues.
• Chronic pain: pain relief, pelvic floor physical therapy, nerve blocks, and occasionally surgery.

For mild aching, supportive underwear, rest, a cold pack wrapped in a cloth, and acetaminophen (paracetamol) or ibuprofen at the label dose can help.

Frequently asked questions

When is testicle pain an emergency?

Sudden, severe pain in one testicle is an emergency until proven otherwise, because it may be testicular torsion. Go to the ER straight away, especially if there is nausea, vomiting or swelling. Surgery within about 6 hours gives the best chance of saving the testicle.

What causes a dull ache in one testicle?

A dull ache is often from a varicocele, a hernia, mild epididymitis, a hydrocele, or referred pain from the back. Testicular cancer can also cause a dull ache or heaviness. Get any persistent ache or new lump checked.

Can a kidney stone cause testicle pain?

Yes. A stone moving down the ureter often causes severe pain in the side or back that spreads to the groin and testicle on the same side. The testicle looks and feels normal on examination.

Can testicle pain go away on its own?

Pain from a minor knock or brief strain often settles within hours. Pain from infection, hernia or torsion will not. Never wait to see whether sudden severe pain goes away, because torsion can cause permanent damage within hours.

Is testicle pain a sign of cancer?

Testicular cancer is usually a painless lump or swelling, but it can cause aching or heaviness. Any new lump, firmness or change in size should be checked by a doctor.