Scrotal pain can occur in men of all ages, from newborns to the elderly. Etiology The most common causes of scrotal pain include testicular torsion of the appendix testis epididymitis There are a number of less common causes (see Table: causes scrotal pain). Age, presence of symptoms and other findings may help determine the cause. Causes scrotal pain cause suspicious findings diagnostic approach testicular torsion Sudden onset severe, unilateral, constant pain No cremasteric Asymmetric transversely oriented, undescended testes on the affected side Typically, in newborns and in boys after puberty, but can color Doppler sonography Hydatid torsion also occur in adults ( ” a vesicular nonpedunculated structure attached to the cephalic pole of the testis “) Subacute occurrence of pain for several days pain in the upper pole of the testis is present cremasteric Maybe reactive hydrocele, “blue dot sign” (blue or black spot under the skin on the upper part of the testes or epididymis) occurs typically at boys aged 7-14 years on. Color Doppler sonography epididymitis or epididymo infectious usually with gram-negative pathogens in prepubertal boys and older men or in sexually active men, sexually transmitted disease can be non-infectious, resulting from reflux of urine into the vas deferens acute or subacute onset of pain in the epididymis and sometimes in the testicles may urinary frequency, dysuria, recently back lying lifting or pressing cremasteric occurs often scrotal induration, swelling, redness sometimes penile discharge typically occurs in boys after puberty and in men urinalysis and urine culture Nukleinsäureamplifikationstests to Neisseria gonorrhoeae and Chlamydia trachomatisPost-vasectomy, acute and chronic (post-vasectomy pain syndrome) Preceding vasectomy pain during intercourse, ejaculation, or both pain during physical exertion sensitive or “full” epididymis Clinical Evaluation injury Usually trauma of genitalia often swelling, possibly intratesticular hematoma or hematocele color Doppler sonography hernia (clamped) Lange existing painful swelling (often known hernia diagnosis) with acute or subacute pain scrotal mass, in d he large, compressible, possibly with audible bowel sounds not reducible Clinical evaluation immunoglobulin-A-associated vasculitis (Henoch-Schonlein purpura) Palpable purpura (usually the lower limbs and buttocks), arthralgia, arthritis, abdominal pain, kidney disease occurs usually at typically boys aged 3-15 years on Clinical evaluation Sometimes biopsy of skin lesions polyarteritis nodosa fever, weight loss, abdominal pain, hypertension, edema lesions including palpable purpura and subcutaneous nodules Can Can be acute or chronic ischemia and infarction testicles veru rsachen Most common in men aged 40-50 years angiography Sometimes biopsy of the affected organs Referred pain (abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrozökale appendicitis, retroperitoneal tumor, “postherniorrhaphy” pain) Normal scrotal examination Sometimes abdominal tenderness, depending on cause directed examination findings and suspected cause orchitis (usually viral eg mumps, rubella, coxsackievirus, echovirus or parvovirus infection) scrotal and abdominal pain, nausea, fever Unilateral or bilateral swelling, redness of the scrotum Acute and convalescent viral titer Fournier gangrene (necrotizing fasciitis of the perineum) Severe pain, fever, toxic symptoms, redness, blistering or necrosis Sometimes palpable subcutaneous intestinal gases Sometimes recent past abdominal surgery common in older men with diabetes, peripheral vascular disease, or both Clinical evaluation assessment Rascher assessment, diagnosis and treatment are necessary because an untreated testicular torsion can lead to the loss of a testicle. In derAnamnese history of present illness should be determined location (unilateral or bilateral), appearance (acute or subacute) and duration of pain. Important Accompanying symptoms include fever, dysuria, penile discharge and scrotal mass. Patients should be asked about past events, including injuries, pressing or lifting and sexual contact. In reviewing the organ systems (immunoglobulin-A-associated vasculitis [Henoch-Schonlein purpura]) should be sought from causative diseases after symptoms including Purpuraexanthem, abdominal pain and Anthralgie; intermittent scrotal lesions, swelling of the strip or both (hernia); Fever and swelling of the parotid (mumps orchitis) and flank pain, or hematuria (kidney stones). The medical history should of known disorders that can cause radiating pain, be determined, including hernias, abdominal aortic aneurysm, kidney stones and risk factors for serious diseases, including diabetes and peripheral vascular disease (Fournier gangrene) .Körperliche examination, the physical examination begins with a review of vital signs and assessing the severity of pain. The physical examination focuses on the abdomen, the inguinal region and genitals. The abdomen is to be sensitivity and lesions examined (including lateral expansion of the bubble) out. Edges are tapped on the sensitivity costovertebral angle. The inguinal and genital examination should be performed with the patient standing. The inguinal region is controlled to adenopathy, swelling and redness and palpable. On examination of the penis should (sources of bacterial infections) be paid to ulceration, discharge from the urethra and piercings and tattoos. In the scrotal investigation asymmetry, swelling, redness or discoloration, and the positioning of the balls should be (horizontal vs. vertical, high vs. low) are observed. The cremasteric should be a bilateral basis. The testes, epididymis and vas deferens should be palpated for swelling and tenderness. In a swelling of the area should be represented by ultrasound to determine whether the swelling cystic or solid ist.Warnzeichen The following findings are of particular importance: Sudden onset of pain; extreme sensitivity and superscript, horizontally offset testicles (testicular torsion) inguinal or scrotal “nonreducible mass” with severe pain, vomiting and constipation (incarcerated hernia) scrotal or perineal redness, necrotic or blistered skin lesions and toxic symptoms (Fournier gangrene) Sudden onset of pain, hypotension, weak pulse, paleness, dizziness and confusion (ruptured abdominal aortic aneurysm) interpreting the findings, the focus is on to distinguish causes that require immediate treatment from others. Clinical findings provide important information (see table: causes scrotal pain). Aortic aneurysms and Fournier gangrene occur mainly in patients> 50 years the other causes that require immediate treatment, can occur at any age. However, a testicular torsion is most common in newborns and boys after puberty before, the torsion of “testicular appendage” occurs most commonly in prepubertal boys (7-14 years) and epididymitis is most common in adolescents and adults. Severe and sudden pain indicate a testicular torsion or kidney stones. Pain due to epididymitis, inkarzeriertem hernia or appendicitis begin rather slowly. In patients with torsion of the appendix testis and moderate pain that develop over a few days, the pain at the upper pole occur. Bilateral pain suggest an infection through (z. B. orchitis, particularly if accompanied by fever and viral symptoms) or on one said cause. Flank pain of the scrotum radiates is evidence of kidney stones or, in men> 55 years old, abdominal aortic aneurysm. Main findings of scrotal and perineal investigation speak for pain by radiation. Attention must then be paid to extraskrotale diseases, especially appendicitis, kidney stones and, in men> 55 years old, abdominal aortic aneurysm. Anno times scrotal and perineal examination findings often indicate a cause. Sometimes, in the early stages of epididymitis sensitivity and hardening of the epididymis can be localized. At the beginning of a twist, the testicles can clearly stand up, lie horizontally and the epididymis are not particularly sensitive. However, the testis and epididymis are often both swollen and sensitive, a scrotal edema occurs, and it is not possible to differentiate epididymitis from torsion by sampling. However, in a twist is no cremasteric, nor symptoms of sexually transmitted diseases (STD-z. B. purulent discharge from the urethra). If these two findings, so epididymitis is quite likely. Sometimes it is possible to use a scrotal mass, which was caused by a hernia, to feel in the inguinal canal. In other cases, a hernia can be difficult to distinguish from a testicular swelling. Painful erythema of the scrotum without sensitivity of the testis or epididymis should increase the suspected infection, either cellulitis or the early stage of Fournier gangrene. A vasculitic rash, abdominal pain and arthralgias are consistent with a systemic Vaskulitissyndrom as immunoglobulin-A-associated vasculitis or arthritis nodosa.Tests done Usually tests. Urinalysis and culture (all patients) Tests for sexually transmitted diseases (all patients with positive urine analysis, vaginal discharge or dysuria) color Doppler sonography to exclude a twist (no clear alternative cause) Other tests (according to the findings s. Causes scrotal pain ) urinalysis and bacterial culture of urine are always required. Findings of UTI (z. B. pyuria, bacteriuria) indicate epididymitis. Patients with findings of UTIs and patients with urethral discharge or dysuria should be tested for sexually transmitted diseases and other bacterial causes of UTI. Timely diagnosis of torsion is of great importance. If findings can necessarily indicative of a twist, an immediate surgical procedure has priority over tests. If the findings are not unique, and there are no other unique factors that cause acute scrotal pain, a color Doppler sonography is performed. If this is not available, can help a Radionukliduntersuchung, but which is less sensitive and specific. Therapy (n. D. Talk .: In Germany this investigation is not common.) The treatment is directed at the cause and can range from one of bedrest (torsion of the appendix testis) to emergency surgery (testicular torsion). In a testicular torsion, usually is an immediate engagement operatifer (<12 hours after presentation) is required. Delayed surgery can lead to testicular infarction, long-term damage to the testes or the loss of a testicle. A surgical Detorsion the testicle relieves the pain immediately and simultaneously a bilateral orchidopexy prevents recurrence of torsion. Analgesics such as morphine or other opioids are indicated for the relief of acute pain. Antibiotics are indicated for bacterial epididymitis or orchitis. Basics of Geriatrics A testicular torsion is uncommon in older men, and when they occur, the manifestations are usually atypical, so that a diagnosis is delayed. In older men, epididymitis, orchitis and traumas are more common. Occasionally, a hernia, a colon perforation or renal colic can cause scrotal pain in older men. Conclusion A torsion should be considered in patients with acute scrotal pain always be considered, especially in children and adolescents. A rapid and accurate diagnosis is crucial. Other common causes of scrotal pain include torsion of the appendix testis and epididymitis. In case of unclear diagnosis usually a color Doppler sonography done. Main findings of scrotal and perineal investigation speak for pain by radiation.