Testicular Pain is rare but serious condition. It is considered a surgical emergency in young male under the age of 25 years. Testicular pain can be of different types based on the onset and course. Sudden onset severe pain, as found in testicular torsion is referred to as acute testicular pain. However, pain in testicular tumors is mild initially and slowly increases in intensity. This prolonged testicular pain is referred to as chronic testicular pain. Also the pain can be unilateral, i.e. occurring only on the one side or bilateral i.e. occurring on the both sides. The most common cause of an acute testicular pain is testicular torsion.

The various causes of testicular pain are listed in the table given below:

Table 1: Causes of Testicular Pain

Testicular torsion is commonly found in young males and is extremely rare above the age of 30 years. Testicular torsion results in sudden onset severe pain and swelling in the testis. It is a surgical emergency and requires urgent surgery (within 2-4 hours of the pain) otherwise there is risk of permanent testicular damage. Testicular torsion of one testis can also damage the other unaffected testis. Other than torsion of spermatic cord, torsion of testicular appendages (appendix of testis) can also cause testicular pain. Surgery is usually not required for torsion of testicular appendages.

Epididymitis (inflammation of epididymis) and Epididymo-orchitis (inflammation of both epididymis and testis) are other important causes of testicular pain. Other associated symptoms like fever and chills, burning urination, increased frequency of urination, discomfort in lower part of abdomen or penis, etc. might be present in epididymitis and epididymo-orchitis. These symptoms may occur before the onset of testicular pain. Epididymitis and Epididymo-orchitis are more common in sexually active males. The cause is often infectious (Gonococcus, Chlamydia, etc.) and antibiotics are used for the treatment of these conditions.

Testicular abscess can occur as a complication of the testicular torsion, Epididymitis and Epididymo-orchitis and requires surgical drainage.

Blunt trauma to the testes can result in hematoma formation or even rupture of testis in severe cases. These may result in acute testicular pain. Trauma can also result in testicular torsion and/or epididymitis. Surgery might be needed in many cases if severe trauma is suspected.

Viral orchitis (or inflammation of the testes caused by viruses like Mumps, Rubella, Coxsackie, etc.) can result in testicular pain and swelling. Treatment is pain medications and scrotal support. This condition usually resolves in few weeks.

Testicular pain can also occur after vasectomy. This may first occur even years after the vasectomy. There can be numerous causes of post-vasectomy pain (e.g. sperm granuloma at vasectomy site, epididymal swelling, etc.).

Stones in lower segment of the ureter (ureterolithiasis) can cause testicular pain. Blood in urine may be present, but more often it is microscopic bleeding.

Prostatitis can also cause testicular pain, but there will be numerous other symptoms associated with it. The commonly found other symptoms are painful urination, increased frequency of urination, urgency, discomfort in penis, pain in lower abdomen, fever and chills, etc.

Rarely, inguinal hernia can also cause testicular pain by compressing a nerve (genitofemoral nerve). This is an example of referred pain. Other referred pain conditions that can cause testicular pain are genitofemoral neuralgia, ilioinguinal neuralgia, iliac artery aneurysm and acute appendicitis.

Testicular tumors can sometimes present initially with only testicular pain. Young males are most likely to have testicular tumors. Although, the most common presentation is painless enlargement of the testis, the percentage of cases of testicular tumor presenting with testicular pain has been found to be nearly 24%. Because of the chances of metastatic spread of the tumor, testicular tumor is an important (though rare) cause of testicular pain. Treatment approach is usually multipronged, comprising of surgery, chemotherapy and radiotherapy.

Some other rare causes of testicular pain are Lyme Disease, Leukemia, Drug Adverse Effect (most commonly due to Mazindol, a weight reduction promoting drug) and Varicocele. Testicular pain can also occur following sexual arousal and is usually relieved by ejaculation. This is called sexual arousal orchialgia. In some cases, no cause of the testicular pain is obvious even after the surgical exploration. They are referred to as idiopathic orchialgia.