Table 1. Differential diagnosis of chronic testicular pain.
| Etiology | Epidermiology | History | Physical examination | Labs/imaging |
|---|---|---|---|---|
| Scrotal conditions | ||||
| Varicocele | 15% prevalence in adult men | Dull aching, throbbing pain worsened by standing, straining or increased activity | ‘Bag of worms’ on palpation | Doppler ultrasonography showing spermatic vein diameter >3.0 mm with retrograde flow under Valsalva |
| Testicular mass | Most common in young males with an average age of 32 years | Range from painless to dull ache, acute pain possible but uncommon | Mass palpated on examination | Ultrasonography facilitates determination of intratesticular or extratesticular mass testicular mass |
| Spermatocele | Increased incidence in sons of mothers who used DES | Usually asymptomatic | Smooth, round and usually small transilluminating mass on the epididymis | Ultrasonography facilitates detection of the cystic mass in the epididymis |
| Hydrocele | 1% to 2% prevalence in neonates | Swelling of scrotal sac, usually not painful although pain may occur with distention | Trans-illuminating mass | Ultrasonography allows detection of fluid collection in the scrotum and evaluation of the testis |
| Post-procedural pain | ||||
| Post-vasectomy pain | 6% of men seek medical advice within 3 to 4 years post-vasectomy for chronic testicular pain | Scrotal discomfort, History of vasectomy | Tender full epididymis and tender vasectomy site with palpable nodule | None |
| Post-hernia repair pain | Roughly, 15% patients with testicular pain at 5-year follow-up regardless of surgical approach | Burning or stabbing pain with changes in sensation, worsened by activity | Normal genital examination | None |
| Referred pain | ||||
| Mid-ureter stone | Unusual presentation presented in case reports | Colicky unilateral pain | Normal genital examination | Non-enhanced CT allows detection of the mid-ureter stone |
| Indirect inguinal hernia | Unusual presentation presented in case reports | Severe unilateral pain | Hernia noted on examination | Ultrsonography to assess for decreased blood flow to the testis |
DES: diethylstilbestrol, VHL: Von Hippel–Lindau, CT: computed tomography.