Why do testicles hurt?
The testicles are very sensitive organs, which can become painful after minor trauma or minor inflammation. The sensation of pain in the testicles can originate in the testicle itself, in the structures around it or even from problems outside the scrotum, such as in cases of kidney stones or inguinal hernia .
In most cases, testicular pain does not cause major concerns, but there are some serious diseases of the testicles that are considered medical emergencies, and immediate treatment is indicated, such as in the case of testicular torsion. Ignoring severe testicular pain can cause irreversible damage to the testicles.
To better understand the causes of pain in the testicles and scrotum, it is necessary to know the anatomical structures that compose them.
The testicles are formed inside the abdomen and descend into the scrotum before birth in most cases. About 10% of babies are born with at least one of the testicles still inside the abdomen, a situation that is called cryptorchidism . Until the first year of life, most testicles still in the abdominal cavity usually descend towards the scrotum.
Therefore, the correct location for the testicles is in the scrotum, outside the abdomen. As they are on the “outside”, the testicles have a temperature of about 2°C below body temperature, which allows them to function better.
The testicles are not loose inside the scrotal sac, but suspended by the spermatic cord, a kind of cord that is born inside the abdomen and contains nerves, blood vessels, the vas deferens (the structure responsible for transporting sperm) and muscle. cremaster, responsible for the involuntary movement of the testicles.
On top of the testicles, like a wig, is the epididymis, the organ responsible for storing sperm produced by the testicles. The spermatic cord is easily palpable, as is the epididymis.
It is normal for one testicle to hang more than the other, causing asymmetry in the scrotum. The size is also usually a little different, one of them being slightly larger than the other. However, it must be emphasized that a very large difference in size between the two testicles is not normal.
It is also common for the testicles to move involuntarily, rising or falling, staying more or less close to the body, in order to regulate their own temperature. These movements are performed by the cremaster muscle.
As mentioned at the beginning of the text, there are several causes of pain in the testicles, some of little clinical importance, others more serious and requiring emergency care. There are also pain in the testicles that are not exactly due to testicular problems, such as pain radiating from the kidney stone that has migrated to the lower urinary tract, some cases of urinary tract infection, prostatitis and inguinal hernias (hernias in the groin region).
In young adults and adolescents it is common to have complaints of mild testicular pain without other associated symptoms. This condition is usually non-specific and usually disappears over time, often without being able to identify a cause.
Testicular pain conditions should always be investigated by a urologist; those of greatest concern are those who present with severe pain associated with other symptoms, such as fever or swelling of the scrotum.
We will describe below the main diseases that cause pain in the testicles:
Varicocele is a disease caused by the dilation of the veins that drain blood from the testicles. It is a varices of the testicular veins. Varicocele affects up to 15% of the young adult population, with its peak incidence being between 15 and 25 years of age. Most often, varicocele occurs on the left side of the scrotum, affecting the left testicle.
One of the common symptoms of varicocele is pain, discomfort, or heaviness in the scrotal region that worsens throughout the day, especially when we sit or stand for a long time. The pain is usually not severe, which is why most patients take a long time to seek urological care.
Varicocele is divided into 3 degrees:
- Grade 1 : we can only palpate the varicocele when the patient performs the valsalva maneuver (exhaling forcefully against the closed lips, in order to increase the pressure in the abdomen).
- Grade 2: varicocele is palpable when the patient is standing.
- Grade 3: Varicocele is not only easily palpable but visible through the scrotum.
The testicles are very sensitive organs and any trauma causes great discomfort. In most cases, the pain is very severe but temporary, getting better after a few minutes.
In cases of high intensity trauma, such as car accidents and/or aggressions, such as kicks in the scrotum, swelling and ecchymosis (purple spots) may appear. The most serious cases occur when the impact is so strong that it causes the testicle to rupture, a condition that needs surgical repair.
The warning signs of testicular trauma are:
- Persistent pain, which does not improve after 1 or 2 hours of trauma.
- Scrotal pouch swelling.
- Purple spots along the scrotum and in the perineum region.
The testicle torsion occurs when there is a defect in the fixation of the testicle to the scrotum, allowing it to “hang” without fixation, which may rotate and twist the spermatic cord, causing compression of the structures within it. Testicular torsion is a medical emergency as it can lead to testicular necrosis if not reversed in time. Treatment is surgical.
About 50% of cases of acute testicular pain are caused by testicular torsion. This complication can occur at any age, but it is most common before age 21.
The typical symptom of testicular torsion is excruciating testicular pain that appears abruptly, usually after trauma or prolonged physical exercise. Testicular torsion can also occur during deep sleep, when there is great involuntary movement of the cremaster muscle, waking the patient up due to intense pain.
In addition to intense pain, there may also be:
- Nausea and vomiting.
- Swelling of the affected testicle.
- Redness in the scrotum.
- Abdominal pain.
Epididymitis is the name given to inflammation of the epididymis, a condition that is usually caused by an infection. In sexually active men, epididymitis is usually caused by chlamydia or gonorrhea , which are sexually transmitted bacterial infections. Epididymitis can also be caused by the bacteria E.coli, the same bacteria that cause urinary tract infections .
Patients with acute epididymitis may present with acute or subacute onset of pain and swelling of the scrotum. Dysuria (pain to urinate) , purulent discharge from the urethra and/or fever are also frequent . In some cases there may be hematospermia (blood in the semen).
Trauma, vasculitis and autoimmune diseases are the most common non-infectious causes. In these cases, epididymitis is usually chronic, the pain is usually less intense and there is no swelling of the scrotum.
The treatment of epididymitis of infectious origin, in most cases, is done with antibiotics.
Orchitis is inflammation of the testis, usually caused by a viral infection. The most common cases of orchitis are caused by mumps . Orchitis can also be caused by bacteria, often as one of the complications of epididymitis.
In cases of orchitis, there is often testicular pain with swelling and redness of the scrotum. In 30% of cases, both testicles are affected.
Testicular cancer is always a concern for patients with testicular pain, but it is not a common cause of pain. In most cases, the patient has a palpable but painless mass in the testicle. Occasionally there may be pain or discomfort in the scrotal region, but this is not the most common.
Some patients after vasectomy surgery may experience testicular pain due to accumulation of sperm in the epididymis without ejaculation. Over time, the testicles stop producing new sperm and the body absorbs those already stored, with a progressive improvement in the condition.
When to seek medical attention?
Most testicular pain is mild to moderate in intensity and resolves on its own within a short time. Medical evaluation by a urologist is indicated whenever the patient presents testicular pain associated with any of the following characteristics:
- Sudden onset intense pain.
- Persistent pain that lasts for several days.
- Nausea and vomiting.
- Scrotal pouch swelling.
- purple spots on the scrotum and around.
- A palpable mass in or around the testicle.
- Blood in urine or sperm.
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- Referred scrotal pain: case reports and review – Journal of general internal medicine.
- Evaluation of acute scrotum in the emergency department – Journal of pediatric surgery.
- The clinical findings in young adults with acute scrotal pain – The American journal of emergency medicine.