Testicular Pain: Causes and Warning Signs

Testicular pain causes at a glance

Testicular torsion: why speed matters

The testicle hangs on the spermatic cord, which carries its blood supply. In torsion, the testicle twists on the cord, cutting off blood flow. It is most common in adolescents, often in boys with a "bell clapper" anatomy where the testicle is not firmly attached inside the scrotum.

Signs include:

• sudden, severe pain in one testicle, sometimes starting in the lower belly
• nausea and vomiting
• swelling and redness of the scrotum
• the testicle sitting higher or at an unusual angle

Surgery to untwist and secure the testicle within about 6 hours saves it in most cases. After 12 to 24 hours, the chance of saving it falls sharply. Doctors may go straight to surgery when torsion is strongly suspected, without waiting for a scan. Both testicles are usually fixed to prevent a future torsion on the other side.

Some boys have intermittent torsion: brief episodes of sudden pain that resolve on their own. These should be assessed, as surgery can prevent a full torsion.

Epididymitis and orchitis

The epididymis is a coiled tube at the back of the testicle that stores sperm. Epididymitis causes pain and swelling that build over a day or two, often with fever and discomfort when urinating.

• Under 35 and sexually active: usually caused by chlamydia or gonorrhea.
• Over 35, or after urinary procedures: usually caused by bowel bacteria from a urinary infection or an enlarged prostate.
• Children: often post-viral or related to urinary tract anomalies.

Orchitis is inflammation of the testicle itself, classically from mumps in unvaccinated people, causing painful swelling 4 to 7 days after the parotid glands swell.

Other causes of testicle pain

• Referred pain: kidney stones, a hernia, back problems, or nerve irritation can cause pain felt in the testicle even though the testicle is normal.
• Post-vasectomy pain syndrome: chronic ache after a vasectomy in a small proportion of men.
• Chronic scrotal pain (orchialgia): pain lasting 3 months or more, sometimes with no clear cause, related to nerve sensitivity or pelvic floor tension.
• Fournier gangrene: a rare, rapidly spreading infection of the genital skin, more common with diabetes, needing emergency surgery.

How doctors find the cause

The doctor will ask how quickly the pain started, whether there was an injury, urinary or sexual symptoms, fever and nausea. They will examine both testicles, the groin and the abdomen, and check the cremasteric reflex (stroking the inner thigh normally makes the testicle rise; this is usually absent in torsion).

Tests may include:

• urine test and swabs for sexually transmitted infections
• Doppler ultrasound of the scrotum to check blood flow and look for swelling, masses or fluid
• blood tests including tumor markers if a lump is found

Treatment

• Torsion: emergency surgery.
• Epididymitis: antibiotics tailored to the likely cause, and partners treated if an STI is involved. Rest, scrotal support, ice packs and anti-inflammatory pain relief help. Symptoms improve within days, but swelling can take weeks.
• Mumps orchitis: rest, support, ice and pain relief.
• Injury: ice, support and pain relief; surgery for rupture.
• Hernia: surgical repair, urgently if it is stuck.
• Varicocele and hydrocele: often no treatment; surgery for persistent pain, fertility concerns or large size.
• Testicular cancer: removal of the testicle, with further treatment depending on type and stage. Cure rates are very high.

For any testicular pain, use supportive underwear, ice wrapped in a cloth for 15 minutes at a time, and acetaminophen (paracetamol) or ibuprofen following the label dose while you arrange to be seen. Do not delay emergency care for sudden pain.

Frequently asked questions

When should I worry about testicular pain?

Go to the ER immediately for sudden, severe testicle pain, especially with nausea or vomiting, as it may be torsion. See a doctor the same day for pain with swelling, fever or urinary symptoms. Any lump in a testicle, even without pain, should be checked within days.

What causes a dull ache in one testicle?

A dull ache is often caused by a varicocele, epididymitis, a hernia, muscle strain or referred pain from the back or a kidney stone. Testicular cancer can occasionally cause a dull ache or heaviness. See a doctor if it lasts more than a few days or you notice a lump.

Can testicular pain go away on its own?

Mild pain from a minor knock usually settles within an hour. Pain that is sudden and severe should never be left to see if it settles, because torsion can briefly ease while the testicle is still at risk. Infections need treatment.

Can a kidney stone cause testicle pain?

Yes. A stone moving down the ureter often causes severe, wave-like pain in the side or back that spreads to the groin and testicle. The testicle itself feels normal on examination. Blood in the urine is a common clue.