How do I know if it's torsion?

Testicular torsion classically causes sudden severe pain — often with nausea and vomiting — in a boy or young man aged roughly 12 to 18, though it can occur at any age. On examination the affected testis sits high in the scrotum ('high-riding'), the cremasteric reflex is absent, and lifting the testis does not ease the pain (Prehn's sign negative). If you or your child has sudden severe testicular pain, go to an emergency department immediately. Do not wait for an ultrasound appointment — the salvage window is only about six hours from pain onset. Ultrasound is useful when the diagnosis is uncertain, but a clinically suspected torsion goes straight to the operating theatre.

What is epididymo-orchitis and how is it treated?

Epididymo-orchitis is inflammation of the epididymis (the tube behind the testis) and sometimes the testis itself. It typically causes a more gradual onset of pain than torsion — building over hours to days — with tenderness localised to the back of the testis, usually preserved cremasteric reflex, and sometimes fever, urinary symptoms, or urethral discharge. In sexually active men under 35, the usual cause is an STI organism (chlamydia or gonorrhoea), treated with ceftriaxone injection plus two weeks of doxycycline. In older men with BPH, it's more commonly a urinary tract organism, treated with trimethoprim-sulfamethoxazole or cefalexin. A full STI screen, including HIV, is part of standard care.

How do I check for testicular cancer?

Testicular cancer most often presents as a firm, painless swelling or lump in the body of the testis itself — not behind it or above it, which is where epididymal cysts (which are benign) tend to be. It may feel like a pea or irregularity in the smooth surface of the testis. Some men notice a feeling of heaviness in the scrotum. To self-examine: stand in a warm shower, gently support the scrotum, and roll each testis between thumb and fingers, feeling for any firm lump or change from the normal smooth surface. Do this monthly from age 15 to 35. If you find anything new or unusual, see your GP the same week — do not wait. The earlier testicular cancer is found, the simpler the treatment.

I found a lump — does this mean cancer?

Not necessarily. Many scrotal lumps are benign. An epididymal cyst is a smooth, soft lump above and behind the testis that transilluminates (shines a light through it). A hydrocele is a fluid accumulation around the testis that also transilluminates. A varicocele feels like a 'bag of worms' — a soft irregular fullness, most common on the left side, more noticeable when standing. However, any new lump or firmness in the body of the testis itself should be assessed by a GP urgently. An ultrasound is the first investigation, and it's highly accurate. Early-stage testicular cancer is treated successfully in nearly all cases.

What is chronic scrotal pain and can it be treated?

Chronic scrotal pain is defined as pain lasting three months or more. It is a recognised and often frustrating condition with many possible causes including post-vasectomy pain, epididymal cysts, varicocele, referred pain from the spine or groin, nerve entrapment, or ongoing low-grade epididymo-orchitis. A urology assessment to characterise the anatomy and rule out treatable causes is the starting point. Management is usually multimodal: anti-inflammatory medication, nerve-modulating agents (such as low-dose amitriptyline or gabapentinoids), pelvic physiotherapy focusing on the pelvic floor and hip muscles, and pain psychology support. Surgical options (microsurgical denervation of the spermatic cord) are available at specialist centres for refractory cases.

Testicular and scrotal pain

Testicular and scrotal pain: torsion is the emergency, cancer is curable

By Dr HB Lo, FACRRM Reviewed 23 September 2026 9 min read

Testicular or scrotal pain always requires urgent assessment. The priority is ruling out torsion — cord twisting cutting off blood supply, with a six-hour window before permanent loss. Sudden severe pain with a high-riding testis: go to emergency immediately.

The most common cause of acute scrotal pain in adults is epididymo-orchitis — inflammation from an STI (younger men) or urinary tract organism (older men), treated with targeted antibiotics.

Testicular cancer presents as a painless lump and is among the most curable cancers, with around 95% five-year survival. Prompt GP review of any new scrotal lump is key.

Testicular pain — not always an emergency, but always taken seriously

Testicular or scrotal pain is one of the presentations in Australian general practice where getting the diagnosis right matters urgently. Most causes are manageable without surgery. One is not.

Testicular torsion — twisting of the spermatic cord — cuts off the blood supply to the testis. The testis can be saved if surgery is performed within approximately six hours of pain onset. After twelve hours, around half are lost. Beyond twenty-four hours, loss is virtually certain. This single fact drives the entire assessment framework for scrotal pain: every presentation, until evaluated by a clinician, should be treated as a potential torsion until proven otherwise.

Beyond torsion, the other urgent categories are Fournier’s gangrene (necrotising fasciitis of the perineum — a rare but life-threatening surgical emergency), strangulated inguinal hernia, and suspected testicular cancer. Understanding the distinguishing features of each is what allows a GP to direct patients appropriately — to the emergency department immediately, to urgent urology, or to a routine consultation.

A. Core clinical — the AU general-practice framework

The torsion red flag

Per USANZ guidance and eTG Genitourinary, testicular torsion is the must-not-miss diagnosis in any male with acute scrotal pain:

Onset: sudden, severe — often waking from sleep; frequently with nausea and vomiting
Peak age: 12–18 years, but possible at any age
Examination: the affected testis sits high in the scrotum (the spermatic cord twists and foreshortens); cremasteric reflex is absent (tapping the inner thigh normally causes ipsilateral testicular elevation — this reflex disappears in torsion); Prehn’s sign is negative (lifting the testis does not relieve the pain, whereas in epididymo-orchitis it typically does)
Critical rule: do not delay surgical exploration to wait for an ultrasound if the clinical picture is consistent with torsion. Scrotal Doppler ultrasound is a useful diagnostic adjunct when the diagnosis is uncertain — it demonstrates absent or reduced blood flow in the affected testis — but it is not 100% sensitive and a torsion suspected clinically should go to an emergency department immediately for surgical assessment

If you or your child has sudden severe testicular pain, go to the nearest emergency department immediately and state that torsion is suspected.

Epididymo-orchitis

The most common acute scrotal condition in adults presenting to general practice is epididymo-orchitis — inflammation of the epididymis and sometimes the testis itself, usually from infection.

Key distinguishing features from torsion:

Onset is gradual, building over hours to days rather than seconds
Tenderness is localised to the posterior epididymis, not the whole testis
Cremasteric reflex is preserved
Prehn’s sign is positive — lifting the testis eases the pain
May be accompanied by fever, urinary frequency or dysuria, urethral discharge, or recent sexual exposure

Treatment varies by age and risk (Australian STI Management Guidelines, eTG):

Sexually active men under 35: treat empirically for STI organisms (chlamydia, gonorrhoea) — ceftriaxone 500 mg IM single dose plus doxycycline 100 mg twice daily for 14 days. A full STI screen is done at the same time, including first-pass urine NAAT for chlamydia, gonorrhoea, and trichomoniasis, syphilis serology, and HIV test. Partner notification and contact tracing are part of management.
Older men with BPH or urinary symptoms: UTI organisms (typically E. coli) — trimethoprim-sulfamethoxazole, cefalexin, or ciprofloxacin for 14 days guided by urine culture and sensitivities
Severe sepsis: inpatient IV antibiotics and admission

Adjunct measures include scrotal support, NSAIDs for pain and inflammation, ice, and rest. Review at one week.

The scrotal differential

Cause	Key feature	Action
Testicular torsion	Sudden severe pain; high-riding; absent cremasteric reflex; Prehn negative	Emergency: ED immediately
Fournier’s gangrene	Pain disproportionate to examination; skin breakdown; crepitus; sepsis	Emergency: ED immediately
Strangulated hernia	Irreducible lump; bowel obstruction features; cough impulse	Emergency: ED immediately
Epididymo-orchitis	Gradual onset; posterior epididymis tender; cremasteric preserved; Prehn positive	Antibiotics; STI screen
Testicular cancer	Painless firm lump in body of testis; younger male	Urgent urology + ultrasound
Hydrocele	Soft transilluminable swelling; painless	Observe or refer if symptomatic
Varicocele	“Bag of worms” especially on standing; left predominant	Refer if symptomatic or affecting fertility
Inguinal hernia	Cough impulse; extends into groin	Surgical referral
Referred pain (renal colic)	Loin-to-groin radiation; haematuria; colicky	MSU, imaging
Epididymal cyst	Above and behind testis; smooth; transilluminates	Reassure

B. Evidence appraisal — torsion time-sensitivity, STI treatment, and scrotal ultrasound

The torsion salvage window

The six-hour salvage window is the central fact in torsion management. USANZ data is consistent with international series: testicular salvage rates decline sharply after six hours — approximately 90% at under six hours, around 50% at twelve hours, and approaching zero at twenty-four hours. The bell-clapper deformity (high attachment of the tunica vaginalis to the spermatic cord) that predisposes to torsion is often bilateral, which is why the contralateral testis is fixed at the same surgical exploration (bilateral orchidopexy) even if it currently appears normal.

The critical medico-legal point documented in this condition: failure to diagnose torsion is the dominant source of medical negligence claims in scrotal conditions. Time of pain onset and clinical management decisions must be documented clearly.

Scrotal ultrasound — useful but not a gatekeeping tool for torsion

Scrotal Doppler ultrasound is excellent at demonstrating absent blood flow in the torsed testis, at identifying tumours, characterising hydroceles and varicoceles, and assessing epididymo-orchitis. For this reason it is the first investigation for most non-emergency presentations.

However, ultrasound has a false-negative rate for torsion. A testis with incomplete torsion may retain some blood flow detectable on Doppler. In a young person with sudden severe pain and clinical features consistent with torsion, the surgical exploration must not be delayed pending an ultrasound result. Ultrasound is for confirming or characterising when the diagnosis is uncertain — not for excluding torsion when it is suspected.

C. Testicular cancer — the most curable cancer in young men

Per Cancer Council Australia, approximately 900 Australian men are diagnosed with testicular cancer each year. The peak age is 15–35 years, and the lifetime risk for an Australian male is approximately 1 in 280. Despite being the most common cancer in this age group, it is also among the most curable: the five-year survival rate is approximately 95%, even accounting for metastatic disease, because testicular germ-cell tumours respond exceptionally well to platinum-based chemotherapy.

Presentation: a firm, painless lump in the body of the testis is the most common presentation. Some men notice a dragging heaviness in the scrotum, or a dull ache. A small proportion present with symptoms of metastatic disease — back pain from retroperitoneal lymphadenopathy, or a swelling in the neck (Virchow’s node from left-side supraclavicular involvement).

Important: a testicular mass should never be biopsied through the scrotum, as this risks seeding cancer cells into scrotal skin and lymphatics. The standard operation is inguinal orchidectomy — removal through the groin approach.

Workup after finding a testicular mass: scrotal ultrasound (very high sensitivity for tumour), tumour markers (AFP, beta-hCG, LDH), urgent urology referral. After orchidectomy, CT chest, abdomen, and pelvis for staging. Multidisciplinary management follows, including surveillance, chemotherapy, or radiotherapy depending on tumour type and stage.

Sperm banking should be discussed and offered before any treatment that might affect fertility — most commonly before chemotherapy.

Risk factors include a history of cryptorchidism (undescended testis, even if surgically corrected), family history of testicular cancer, and a previous testicular cancer in the other testis.

D. Australian operations

Most initial scrotal presentations are assessed in general practice. Standard consultation items (MBS items 23, 36, 44) apply. In-person examination is required; telehealth is not appropriate for the initial assessment of acute or uncertain scrotal pathology.

Investigations: scrotal Doppler ultrasound (MBS item 55041) is the principal imaging modality. Pathology items include FBC (65070), CRP (66509), MSU (MBS microbiology), and first-pass urine NAAT for STIs (69405 range). Syphilis serology and HIV are standard STI screen components. Tumour markers AFP, beta-hCG, and LDH are covered under relevant biochemistry MBS items.

Antibiotics on the PBS: ceftriaxone IM for epididymo-orchitis requires Authority. Doxycycline is on the General Schedule. Trimethoprim-sulfamethoxazole, cefalexin, and ciprofloxacin are General Schedule. NSAIDs are General Schedule or over-the-counter. Chronic scrotal pain — gabapentin, pregabalin, and amitriptyline for chronic pain are Authority Required.

Cancer pathway: suspected testicular cancer warrants an urgent two-week urology referral with ultrasound and tumour markers pre-booked. Most major Australian hospitals have a urology and oncology multidisciplinary team. Testicular cancer is managed under standard oncology care; no special funding pathway is needed to initiate the referral.

Mental health: chronic scrotal pain and testicular cancer carry significant psychological burden. A Mental Health Care Plan (MBS items 2715/2717) is appropriate for either, and referral to a pain psychologist or oncology psychologist respectively is often valuable.

E. Special populations

Boys and adolescents. Testicular torsion is most common at puberty, when the testes are growing rapidly. Any adolescent boy or the parent of a young boy should be explicitly counselled: sudden severe testicular pain is an emergency — go to the emergency department, not a GP, and not in the morning. The six-hour window doesn’t allow time for a next-day appointment.

Older men with BPH. Epididymo-orchitis in men over 40–50 is typically caused by urinary tract organisms refluxing from a structurally obstructed urinary tract related to benign prostatic hyperplasia. These men need a mid-stream urine culture, and the antibiotic choice should follow the culture result. A PSA and urological review for the underlying BPH is also part of comprehensive management in this population.

Men with previous cryptorchidism. A history of undescended testes (cryptorchidism) — even if surgically corrected in childhood — increases the lifetime risk of testicular cancer approximately three- to five-fold. These men should be counselled about monthly self-examination and the importance of reporting any new testicular lump promptly.

Tropical infections. Filariasis (lymphatic filariasis from Wuchereria bancrofti) can cause scrotal swelling and secondary hydrocele — relevant in men born in or recently returned from endemic areas (sub-Saharan Africa, South and Southeast Asia, Pacific Islands). This is uncommon in Australia’s domestic population but worth considering in the appropriate travel or migration context.

When to escalate

Refer or direct to emergency department:

Suspected torsion — emergency department immediately, not a GP
Fournier’s gangrene — emergency department immediately
Strangulated inguinal hernia — emergency department
Suspected testicular cancer — urgent urology within days
Severe sepsis from epididymo-orchitis — emergency department

Refer to urology:

Suspected cancer — urgent, within days
Epididymo-orchitis not responding at one-week review
Varicocele with infertility — for surgical ligation or embolisation
Symptomatic hydrocele
Chronic scrotal pain (≥3 months) — urology assessment, then multidisciplinary pain team
Previous torsion — orchidopexy of contralateral testis if not already done

What this article is and is not

This article is general health information based on current Australian clinical guidelines — USANZ, eTG Genitourinary, AMH, Australian STI Management Guidelines, and Cancer Council Australia. It is not personal medical advice. Scrotal pain requires clinical assessment; sudden severe pain requires emergency attendance — this article is not a substitute for that.

For consumer resources: HealthDirect — testicular pain, HealthDirect — testicular cancer, Healthy Male (Andrology Australia), Cancer Council Australia, Better Health Channel.

Sources cited

Frequently asked questions

How do I know if it's torsion?

Testicular torsion classically causes sudden severe pain — often with nausea and vomiting — in a boy or young man aged roughly 12 to 18, though it can occur at any age. On examination the affected testis sits high in the scrotum ('high-riding'), the cremasteric reflex is absent, and lifting the testis does not ease the pain (Prehn's sign negative). If you or your child has sudden severe testicular pain, go to an emergency department immediately. Do not wait for an ultrasound appointment — the salvage window is only about six hours from pain onset. Ultrasound is useful when the diagnosis is uncertain, but a clinically suspected torsion goes straight to the operating theatre.
What is epididymo-orchitis and how is it treated?

Epididymo-orchitis is inflammation of the epididymis (the tube behind the testis) and sometimes the testis itself. It typically causes a more gradual onset of pain than torsion — building over hours to days — with tenderness localised to the back of the testis, usually preserved cremasteric reflex, and sometimes fever, urinary symptoms, or urethral discharge. In sexually active men under 35, the usual cause is an STI organism (chlamydia or gonorrhoea), treated with ceftriaxone injection plus two weeks of doxycycline. In older men with BPH, it's more commonly a urinary tract organism, treated with trimethoprim-sulfamethoxazole or cefalexin. A full STI screen, including HIV, is part of standard care.
How do I check for testicular cancer?

Testicular cancer most often presents as a firm, painless swelling or lump in the body of the testis itself — not behind it or above it, which is where epididymal cysts (which are benign) tend to be. It may feel like a pea or irregularity in the smooth surface of the testis. Some men notice a feeling of heaviness in the scrotum. To self-examine: stand in a warm shower, gently support the scrotum, and roll each testis between thumb and fingers, feeling for any firm lump or change from the normal smooth surface. Do this monthly from age 15 to 35. If you find anything new or unusual, see your GP the same week — do not wait. The earlier testicular cancer is found, the simpler the treatment.
I found a lump — does this mean cancer?

Not necessarily. Many scrotal lumps are benign. An epididymal cyst is a smooth, soft lump above and behind the testis that transilluminates (shines a light through it). A hydrocele is a fluid accumulation around the testis that also transilluminates. A varicocele feels like a 'bag of worms' — a soft irregular fullness, most common on the left side, more noticeable when standing. However, any new lump or firmness in the body of the testis itself should be assessed by a GP urgently. An ultrasound is the first investigation, and it's highly accurate. Early-stage testicular cancer is treated successfully in nearly all cases.
What is chronic scrotal pain and can it be treated?

Chronic scrotal pain is defined as pain lasting three months or more. It is a recognised and often frustrating condition with many possible causes including post-vasectomy pain, epididymal cysts, varicocele, referred pain from the spine or groin, nerve entrapment, or ongoing low-grade epididymo-orchitis. A urology assessment to characterise the anatomy and rule out treatable causes is the starting point. Management is usually multimodal: anti-inflammatory medication, nerve-modulating agents (such as low-dose amitriptyline or gabapentinoids), pelvic physiotherapy focusing on the pelvic floor and hip muscles, and pain psychology support. Surgical options (microsurgical denervation of the spermatic cord) are available at specialist centres for refractory cases.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.

T1 AU primary 9 sources