Scrotal pain in young men is a frequent reason for emergency department visits and urology consultations. While many underlying causes are benign and self-limiting, others, most notably testicular torsion, represent true urologic emergencies in which delayed intervention can result in irreversible testicular damage.

The clinical challenge lies in distinguishing conditions that allow for short-term observation from those requiring immediate evaluation. This distinction is particularly important in adolescents and young adults, where embarrassment, fear, or symptom minimization may delay presentation.

Understanding the differential diagnosis

The scrotum contains multiple vulnerable structures, including the testes, epididymides, spermatic cords, and associated vascular and neural elements. Pain may arise from inflammatory, infectious, vascular, traumatic, or referred causes.

Common etiologies include:

• Testicular torsion
• Epididymitis and orchitis
• Trauma-related injury
• Torsion of testicular appendages
• Inguinal hernia
• Varicocele or hydrocele
• Referred pain from renal or musculoskeletal sources

Clinical presentations often overlap, making careful history and physical examination essential.

When scrotal pain requires urgent evaluation

Acute onset of severe unilateral pain

Sudden, intense unilateral scrotal pain should be considered testicular torsion until proven otherwise. Torsion is most common in adolescents but can occur at any age.

Associated features may include nausea or vomiting, scrotal swelling, erythema, a high-riding or transverse testis, and an absent cremasteric reflex. Testicular viability declines rapidly after six hours of ischemia. When clinical suspicion is high, surgical exploration should not be delayed for imaging.

Persistent pain following trauma

Blunt scrotal trauma may initially appear mild. However, persistent pain, progressive swelling, or testicular firmness raises concern for testicular rupture or hematocele and warrants urgent ultrasonographic evaluation and possible surgical intervention.

Pain with systemic signs of infection

Scrotal pain accompanied by fever, chills, malaise, or rapidly progressive erythema suggests infectious etiologies such as epididymo-orchitis. In rare cases, necrotizing infections of the perineum must be considered. Early recognition and treatment are essential to prevent infertility, sepsis, and tissue loss.

Pain associated with urinary or sexually transmitted infection symptoms

Scrotal pain accompanied by dysuria, urethral discharge, or recent unprotected sexual activity is concerning for sexually transmitted epididymitis. Prompt diagnosis and guideline-directed antimicrobial therapy reduce the risk of chronic pain and impaired fertility.

Testicular carcinoma: An often-overlooked diagnosis

Testicular carcinoma is the most common solid malignancy in men aged 15 to 40 years. It is classically described as a painless testicular mass; however, up to 20 percent to 30 percent of patients report scrotal discomfort, dull ache, or heaviness rather than overt pain.

Features that should raise suspicion include:

• A firm or enlarging intratesticular mass
• Persistent unilateral scrotal discomfort
• Testicular asymmetry or induration
• Associated back pain, cough, or weight loss (suggesting metastatic disease)

Importantly, testicular cancer is frequently misattributed to epididymitis or trauma, leading to delayed diagnosis. Any intratesticular lesion identified on ultrasound should be considered malignant until proven otherwise and warrants urgent urologic referral.

Early-stage testicular cancer has an excellent prognosis, with cure rates exceeding 95 percent when diagnosed promptly. Delay in evaluation remains one of the few modifiable risk factors affecting outcome.

When observation may be reasonable

Not all scrotal pain requires emergency intervention, but all cases warrant medical assessment.

Gradual onset of mild discomfort without systemic symptoms may be related to low-grade inflammation, musculoskeletal strain, or referred pain. Patients with known, stable conditions such as varicocele or hydrocele may experience intermittent discomfort that can be managed with outpatient follow-up if symptoms are unchanged.

Activity-related or positional discomfort may resolve with rest and scrotal support. However, recurrence, progression, or diagnostic uncertainty should prompt urologic evaluation.

Key clinical principles

• Acute scrotal pain is torsion until proven otherwise.
• Young age does not exclude serious pathology.
• Delayed presentation remains a major contributor to testicular loss.
• When uncertainty exists, early evaluation is preferable to delayed reassurance.

Final thoughts

Scrotal pain in young men requires a vigilant and structured clinical approach. While many cases are benign, the consequences of missed or delayed diagnosis, particularly in testicular torsion, are significant and often irreversible.

Reassurance is appropriate only after serious causes have been excluded. Prompt evaluation protects not only testicular viability but also long-term reproductive and hormonal health.

Martina Ambardjieva is a dedicated urologist and medical educator with extensive experience in both clinical practice and academic instruction. She earned her MD from the University “Sv. Kiril i Metódij” in Skopje and is a PhD candidate in urological oncology, with a focus on bladder carcinoma. Her scholarly work includes numerous publications in oncologic urology, urinary calculosis, and men’s health.

Dr. Ambardjieva currently serves as a urologist at the PHI University Surgical Clinic “Naum Ohridski” and completed her residency training at the University Urology Clinic in Skopje. Earlier in her career, she practiced as a general medical doctor at Sante Plus General Hospital and completed a medical internship at the University of Ljubljana.

In addition to her clinical responsibilities, Dr. Ambardjieva is a teaching assistant at the Medical Faculty in Skopje. She works additionally as a collaborator for Dr. Telx. She has held leadership positions in the European Medical Students’ Association and actively participates in international medical education and policy. She has attended numerous congresses and workshops in France, Italy, Canada, and Turkey, and serves as a delegate for the European Association of Urology (EAU), contributing to cross-border initiatives in urology. Certified in laparoscopic surgery, she continues to integrate patient care, research, and education in her professional work.