GPAtlas🧭 When to suspect
Acute scrotal pain is a can't-miss presentation. Two diagnoses dominate: testicular torsion (twisting of the spermatic cord, cutting off the testicular blood supply – a surgical emergency) and epididymo-orchitis (infection or inflammation of the epididymis, with or without the testis). Torsion must be considered and excluded first in every case, particularly in adolescents and young men.
The governing principle is that torsion is time-critical. Testicular salvage approaches 90–100% within 6 hours of onset, falls to roughly 50% by 12 hours, and is unlikely beyond 24 hours. No clinical sign is sensitive enough to exclude torsion, so if it is on your differential the patient needs same-day surgical assessment – not watchful waiting or an outpatient scan. If in doubt, explore.
The second skill is risk-stratifying epididymo-orchitis by age and history, because it drives empirical antibiotics: under 35 or sexually active → think Chlamydia and gonorrhoea (refer to sexual health); over 35 or recent urinary-tract instrumentation → think enteric (coliform) organisms.
| Feature | Testicular torsion | Epididymo-orchitis |
|---|---|---|
| Typical age | Neonates and pubertal boys (peak 12–18y); can occur at any age | Any age; < 35y usually STI-related, > 35y usually enteric/UTI-related |
| Onset & tempo | Sudden, severe, often < 6h; may wake from sleep | Gradual, over hours to days |
| Nausea / vomiting | Common | Uncommon |
| Cremasteric reflex | Usually absent on affected side | Usually present |
| Testicular lie | High-riding, horizontal | Normal vertical lie |
| Urinary / urethral symptoms | Absent | Dysuria, frequency, urethral discharge may be present |
| Prior episodes | Previous self-limiting episodes suggest intermittent torsion | Not typical |
Source: BASHH · BAUS
|
🧠 Clinical pearl Always ask about previous self-limiting episodes. A history of recurrent, brief, severe scrotal pain that settled on its own points to intermittent torsion. These boys are at high risk of a completed torsion and warrant urology referral for consideration of elective bilateral fixation (orchidopexy) – even though the testis looks entirely normal on the day you see them. |
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