What are the common causes of testicular pain?
There are many causes of testicular pain. Epididymitis (inflammation/infection of the epididymis) and epididymo-orchitis (epididymis + testes) are the most common causes of acute scrotal pain in adults. The most important cause to identify and treat immediately is testicular torsion, where there is twisting of the spermatic cord that can cut off blood supply to the testes - this is an emergency.
Other causes include trauma to the region, inguinal hernia, hydroceles, varicoceles, kidney stones (referred pain), post-vasectomy pain, prostatitis, neuropathic pain, and even testicular cancer (which can either be painless or sometimes be painful).
What is epididymitis, and how does it differ from orchitis?
Epididymitis is inflammation of the coiled tube-like structure behind the testes that stores sperm.
Orchitis is inflammation of the testes itself.
These 2 conditions can happen independently of each other or together. Isolated orchitis is often viral (classically mumps), whereas epididimitis-orchitis (EO) is usually caused by a bacterial infection and typically involves the epididymis first.
What is epididymo-orchitis (EO), and how serious can it be?
EO is when infection/inflammation involves both epididymis and testes. It typically is a bacterial infection. Most cases respond to treatment with antibiotics and supportive care.
Delayed or severe cases can lead to complications such as abscess and sepsis,, testicular atrophy, chronic pain, or even impaired fertility. If you suspect you have EO, seek medical attention promptly.
Can testicular pain always mean infection, or could it be something else?
No. Infection is usually the most common cause, but torsion, trauma, hernia, stones, nerve/referred pain, or tumours can cause similar symptoms. Torsion must always be excluded in sudden, severe and progressively worsening pain because damage to the testicles can be permanent.
What symptoms should I look out for if I suspect epididymitis or orchitis?
Typical features include testicular/scrotal pain, swelling and tenderness, and warmth. There may also be an accompanying fever, urinary symptoms such as dysuria/frequency/urgency, or urethral discharge. Viral orchitis (e.g., mumps) can present with fever and parotid swelling.
Does testicular pain always come with swelling or redness?
Not always. Early infection or referred pain may cause discomfort without obvious swelling. That said, new swelling, redness, or if the symptoms are progressively and rapidly worsening warrants assessment. Any rapidly escalating pain is urgent until torsion is ruled out.
When should I seek urgent medical attention for testicular pain?
Seek medical attention if you have sudden, severe testicular pain (especially with nausea/vomiting or a high-riding, very painful testes) to rule out torsion. If there is a fever with severe scrotal pain/swelling, or feeling systemically unwell. Or if there is a history of trauma followed by persistent swelling and pain.
Can epididymo-orchitis cause fever, nausea, or urinary symptoms?
Yes. Patients with EO can have fever, malaise, pain/burning on passing of urine, urinary frequency/urgency, or urethral discharge. Nausea and vomiting can occur with severe pain.
What infections commonly cause epididymo-orchitis?
In younger men or in men with a history of new sexual partners, we always suspect a sexually transmitted infection. The 2 most typical organisms are Chlamydia trachomatis and Neisseria gonorrhoeae.
In older men, or patients with a history or urinary tract issues, or post-instrumentation (e.g recent catheter insertion), or men who participate in insertive anal intercourse we usually suspect Enteric and urinary pathogens - typically E. coli, Gram-negative, or anaerobic bacteria.
Can sexually transmitted infections (STIs) cause testicular pain?
Yes. Chlamydia and gonorrhoea can infect the epididymis/testes and cause EO. They are a common cause of testicular pain especially in young adults.
Are urinary tract infections (UTIs) linked to epididymo-orchitis?
It is possible. Bacterial spread from the urinary tract or prostate to the epididymis/testes is a recognised pathway, particularly in older men or those with pre-existing urological issues or recent urological procedures.
Can injury, tight clothing, or prolonged sitting trigger testicular pain?
Tight clothing may result in mild trauma which can inflame the testes/epididymis. Prolonged pressure (e.g in cycling or long sitting) may cause some discomfort especially in patients with pre-existing varicoceles or hydroceles.
These factors don’t usually cause a bacterial infection on their own but may exacerbate symptoms.
How is epididymo-orchitis diagnosed?
EO is diagnosed with a history and physical examination. Typically investigations will be done as well.
What tests (e.g., urine test, ultrasound, STI screening) are needed?
To look for causes of the EO, we may do a urine or swab test to check for causative organisms. A scrotal ultrasound with doppler should be done to assess blood flow and is helpful to exclude torsion and detect complications such as abscess. Blood tests may be added if you’re febrile or systemically unwell and also to screen for other STIs as appropriate.
What are the treatment options for epididymo-orchitis?
As EO is typically a bacterial infection, antibiotics are usually used. Depending on what we suspect, different antibiotic regimes may be used. If tests are done, they can help guide treatment as well.
Supportive management with analgesia, anti-inflammatories and rest are also an important part of treatment.
How long does it usually take to recover from testicular pain or EO?
With correct antibiotic treatment, relief from the pain often happens within a few days. Swelling and tenderness can take weeks to fully resolve. If there is no relief/worsening of the pain, this warrants re-evaluation.
Can epididymo-orchitis affect fertility if not treated promptly?
Most men recover fully, but significant inflammation can temporarily affect sperm quality. Severe/complicated infections can lead to testicular damage and atrophy or, rarely, sub-fertility/infertility. Prompt diagnosis and treatment minimise these risks.
Medically reviewed by Dr. Harold Ma, and Dr. Chester Lan.