Postgrad Med J: first published as 10.1136/pgmj.63.741.521 on 1 July 1987. Downloaded from Postgraduate Medical Journal (1986) 63, 521-523 Leading Article Scrotal pain R.J. Morgan and J.R.W. Parry Department of Urology, The Whittington Hospital, Highgate Hill, London N19 5NF, UK. Scrotal pain is a common and worrying symptom for procedures should be warned ofthe possibility of such which an adequate explanation cannot always be pain thereafter. found. In this issue of the Postgraduate Medical Testicular torsion commonly presents with acute Journal Dr Watanakunakorn' adds to the long list of pain accompanied by swelling and redness of the possible causes of this form of pain. scrotum in children or young adults. However, Chap- The nerve supply of the scrotum and its contents is man & Walton2 in their study based at the London derived from disparate parts of the nervous system. Hospital, showed that 44% of patients with testicular Within the scrotum, the testis, vas and epididymis torsion initially presented with recurrent briefepisodes appear to be innervated by sympathetic fibres from of scrotal discomfort. Such 'warning' pains presuma- TI-T12 and TI-LI respectively, whilst the outer bly were relieved by the spontaneous untwisting ofthe surface of the testis, the tunica vaginalis and the cord. It remains imperative that any person suspected anterior scrotal skin receive somatic fibres from L1- of having a testicular torsion should have an emer- L2. The rest ofthe scrotal skin is innervated by somatic gency surgical exploration of the scrotum. At such an copyright. branches of S2-S3. Pain felt in the scrotum may operation the pain and swelling is occasionally found therefore be referred from visceral or somatic struc- due to a torsion of the appendix testis (pedunculated tures with the same segmental nerve supply. Thus a hydatid of Morgagni). Very occasionally the clinical stone impacted in the lower ureter, with a splanchnic diagnosis can be made before the operation ifthe child LI innervation, may cause scrotal pain in this way, as is seen early enough to allow the doctor to identify a may compression of the genitofemoral nerve by a tender swelling localized to the upper pole ofthe testis. small inguinal hernia, or, exceptionally, an aneurysm More commonly the scrotum becomes swollen and of the internal iliac artery. Degenerative lesions of the painful too quickly to permit such discrimination. http://pmj.bmj.com/ spine and, rarely, inflammatory or neoplastic disease Spontaneous fat necrosis and ideopathic scrotal of genital viscera may cause a similar referred pain. oedema are often listed as possible differential diag- Pain which is generated by some change within the noses of testicular torsion in children. These excep- scrotum itself usually stimulates somatic as well as tionally rare disorders should only be diagnosed after autonomic fibres and is therefore accurately localized surgical exploration has taken place. to the scrotum. True orchitis may involve one or both testicles and is Cystic swellings of the scrotum rarely cause pain, seen most commonly in this country in association on September 23, 2021 by guest. Protected although a very large hydrocele may cause discomfort with mumps. Although not likely to cause long term by dragging on the cord or by distension of the tunica problems in childhood, such orchitis can cause tes- vaginalis. Should bleeding occur in a hydrocele or in ticular atrophy in the 15% ofadults with mumps who an epididymal cyst or should they become infected, develop testicular pain and swelling. Draining a commonly after needle aspiration, then both may secondary hydrocele and incising the tunica albuginea become acutely painful. Varicoceles are usually pain- may relieve the pain in extreme cases. Infectious less swellings, but exceptionally large ones can ache mononucleosis, dengue fever and infection with cox- after exercise or after long periods of standing. sackie B virus may all occasionally produce an Patients occasionally present with acute pain as a orchitis, whilst rarely an arteritis (Buerger's disease, result ofthrombosis within the varicocity. Such pain is polyarteritis nodosa, Henoch-Sch6nlein purpura) often encountered after high ligation or embolization may present in this way. of a varicocele and patients who undergo such In an adult the commonest cause of acute scrotal pain is epididymal infection. Before the antibiotic era gonorrhoea was regarded as the commonest cause of Correspondence: R.J. Morgan FRCS acute epididymitis, but now infecting organisms are Received: 26 February 1987 not always easily identified. Mittemeyer et al.3 were D The Fellowship of Postgraduate Medicine 1987 Postgrad Med J: first published as 10.1136/pgmj.63.741.521 on 1 July 1987. Downloaded from 522 R.J. MORGAN & J.R.W. PARRY only able to identify a bacterial cause in a quarter of the pain is associated with a rapidly spreading gan- 610 cases occurring in United States soldiers. Most of grene ofthe scrotal skin caused by a mixture ofaerobic the organisms which were cultured were coliforms. and anaerobic organisms. With prompt antibiotic Although trauma and the spontaneous reflux of urine therapy most cases can be arrested, but subsequent down the vasa were postulated as causes in those in debridement and surgical reconstruction of the whom cultures were negative, it is now realised that scrotum is generally necessary. infection with D to K serotypes of Chlamydia tra- Scrotal trauma, if severe, may cause a testicular or chomatis and more rarely mycoplasma would proba- scrotal haematoma. If there is a question of testicular bly have accounted for the attacks of 'sterile' rupture, the scrotum should be explored, debrided and epididymitis.4 the tunica repaired. Signs of considerable scrotal The route by which infecting organisms reach the injury with a history of minor trauma should alert the epididymis is uncertain, but such evidence as there is clinician to the possibility of an underlying testicular points towards the passage being by lymphatics or by tumour. Scrotal pain, swelling and bruising with the tissue spaces surrounding the musculature of the passage of blood from the urethra and an inability to vas. Not only can epididymitis occur after a vasectomy pass urine all suggest the possiblity of a urethral but also it seems unlikely that urine can reflux down rupture. the vas in a healthy male. A valvular mechanism The causes of scrotal pain so far described have all normally exists at the opening to the ejaculatory ducts been associated with obvious clinical pathological and the direction ofmuscular contraction waves in the processes, but very many patients who present with vasa, the activity ofcilia and the blockage of the ducts such pain have no immediately obvious intrascrotal by semen would make retrograde urine flow unlikely. pathology. In such cases a careful examination of the Certainly Lapides5 found the urethral pressure always surface of the testis and epididymis may reveal a exceeded the bladder pressure during straining and no localized tender nodule on the surface ofthe testis. On reflux can be demonstrated radiologically during ultrasound scanning the nodule can be seen to cause an cystography in patients with epididymitis. acoustic shadow and at scrotal exploration a localized If the antibiotic treatment of a bacterial epi- area of nodular peri-orchitis may be encountered.7copyright. didymitis is delayed or unsuccessful, the infection can This is a common condition, a result of an inflamma- progress to abscess formation with destruction of the tion within the vaginal space, leading to a chronic epididymis and involvement of the testis. In these hypertrophic serositis, characterized by collagenous circumstances an orchidectomy is usually required. A thickening and nodularity of the tunica vaginalis. similar clinical picture to that of acute epididymitis These areas generally become less tender and may may be seen in cases of spontaneous extravasation of separate from the tunica to become loose bodies in the sperms into the epididymis, causing a seminal gran- vaginal space. They need not be removed. uloma with localized pain, tenderness and swelling. Where pain is associated with the testis being drawn http://pmj.bmj.com/ Where leakage of sperms occurs at the site of vasec- up to the external inguinal ring, cremasteric spasm is tomy similar sperm granulomas may form in the the likely cause. This may be relieved by circumcision adjacent soft tissues and may persist as locally painful of the cremaster and therefore division of the genito- nodules. femoral nerve. Many young men with scrotal pain Whenever an inflammatory testicular swelling fails have no more to find than a tender and prominent to resolve with treatment the possibility ofan underly- epididymis. These men may be reassured, their pain ing testicular tumour should always be considered as seminal If possibly being caused by congestion. a on September 23, 2021 by guest. Protected approximately 10% oftesticular tumours may present persistent ache is described within the body of the with pain and an impression ofan inflammatory mass. testis an ultrasound examination should be performed In such cases of doubt regarding the clinical diagnosis to exclude a small impalpable central testicular ofan intrascrotal swelling the use ofscrotal ultrasound tumour. Scrotal pain with no obvious cause may rarely can be of great help in determining the nature of the precede the eruption of the vesicles of herpes zoster. pathological change. The classical ultrasound More often, when both local causes and the possibility appearance of a variety ofintrascrotal disease proces- of referred pain have been excluded, no immediate ses has been described.6 No such confusion of diag- explanation for the pain can be given and the patient nosis applies to the spectacular appearance and will be best served by a frank explanation that no explosive clinical course ofFournier's gangrene, where serious cause for the pain exists. Postgrad Med J: first published as 10.1136/pgmj.63.741.521 on 1 July 1987.