Acute and Chronic Scrotal Pain Algorithm

Safety

Step 1 — Immediate Safety Screen: Torsion & Other Emergencies

Done

Sudden-onset or severe unilateral scrotal pain is a surgical emergency until torsion has been excluded. Do not delay urgent transfer or urological assessment for ultrasound, blood tests or response to analgesia. Give appropriate analgesia while arranging immediate transfer.

Use the local emergency pathway: transfer immediately to an emergency department or surgical/urological service able to assess and operate. Call 999 for an ambulance if there is haemodynamic instability, severe systemic illness, inability to transfer safely or another emergency indication. Children and young people: refer immediately to a centre able to provide surgical exploration — do not transfer a child merely to obtain an ultrasound (GIRFT).

Sudden severe unilateral testicular/scrotal pain May radiate to groin/abdomen → Emergency transfer suspected torsion

High-riding or horizontal testis With acute pain → Emergency transfer suspected torsion

Nausea/vomiting with acute testicular pain Any age → Emergency transfer do not delay for USS

Sepsis or haemodynamic instability Fever, rigors, haemodynamic compromise → 999 Emergency Fournier's gangrene / severe epididymo-orchitis

Absent or uncertain cremasteric reflex With acute pain → Emergency transfer suspected torsion

Severe acute pain — torsion not confidently excluded Including suspected appendage torsion where uncertain → Emergency transfer surgical assessment

Irreducible inguinoscrotal hernia Vomiting or abdominal pain → Emergency transfer bowel strangulation

Trauma with expanding haematoma Haematocele or suspected rupture → Emergency transfer testicular rupture

Fournier's gangrene Severe pain, systemic illness, skin necrosis, bullae, crepitus or rapidly progressive swelling → 999 Emergency surgical debridement

Torsion is time-critical: the chance of testicular salvage declines the longer the testis is twisted. The 6-hour figure conveys urgency, but surgery is not futile after 6 hours — salvage may still be possible later. No single history or examination finding reliably confirms or excludes torsion, and colour Doppler ultrasound has a user-dependent false-negative rate; BASHH advises that suspected clinical torsion needs urgent exploration rather than reassurance from imaging. Give analgesia promptly — it must not delay transfer. A painless lump without acute pain follows the suspected cancer route (NICE NG12) — see Scrotal Lumps and Swelling.

Diagnose

Step 2 — Focused History

Done

Take a focused history before examination. Use risk factors, not age alone, to estimate the likely cause and pathogen.

Onset & pattern

Exact time and mode of onset. Sudden → torsion / trauma. Gradual (hours–days) → epididymo-orchitis. Intermittent or recurrent episodes. Insidious → structural cause or chronic pain

Severity & systemic

Severity and functional impact. Nausea/vomiting (raises concern for torsion). Fever or systemic symptoms

Age

Relevant (torsion is commoner in young people; enteric infection in older men with urinary pathology) but must not determine the likely pathogen or treatment by itself — combine with sexual and urinary risk

Sexual history

New or multiple sexual partners, condom use, insertive anal intercourse. Previous STI or epididymo-orchitis. Take sensitively and confidentially

Urinary symptoms

Dysuria, frequency, retention or urethral discharge. Previous urinary infection, catheterisation or instrumentation

Previous episodes

Short-lived severe episodes that resolved → suggest intermittent torsion (urgent urology). Recurrent epididymo-orchitis

Surgery & trauma

Trauma, vasectomy, hernia repair or abdominal surgery. Scrotal swelling or lump → see Scrotal Lumps and Swelling

Referred sources

Loin, groin, hip, back or pelvic-floor symptoms

Fertility

Fertility concerns

Medicines & comorbidity

Medication, comorbidity and immunosuppression

The history sets the urgency before examination. Age is relevant, but the 2024 European epididymo-orchitis guideline cautions against using age as a surrogate for STI risk — estimate the likely pathogen from sexual and urinary risk factors. Previous brief, self-resolving episodes may represent intermittent torsion. Missing sexually acquired infection risks complications and onward transmission. A thorough sexual history is a core RCGP competency and must be taken sensitively.

Diagnose

Step 3 — Differential Diagnosis by Presentation

Done

Classify into the main diagnostic categories to guide investigation and management pathway.

Testicular Torsion

Sudden-onset severe pain ± nausea/vomiting. High or horizontal testis and absent cremasteric reflex increase concern but do not confirm it. Any age. Immediate emergency transfer — do not wait for imaging

Torsion of appendix testis

Localised upper-pole tenderness ± blue-dot sign. If confidently diagnosed: analgesia, support and safety-net. Immediate emergency surgical assessment if uncertain or worsening

Epididymo-orchitis

Usually gradual onset, tender epididymis ± testis, ± fever, urinary or urethral symptoms. Likely pathogen from risk factors, not age alone: sexually acquired (Chlamydia, gonorrhoea, M. genitalium) vs enteric/uropathogen (e.g. E. coli). Test before antibiotics where this will not delay treatment

Hydrocele

Usually painless, transilluminates, surrounds testis. In adults assess clinically; USS if the testis cannot be adequately examined or the cause is uncertain. See Scrotal Lumps and Swelling

Varicocele

"Bag of worms" palpable standing, reduces supine, usually left-sided. May cause dragging ache. Supportive treatment; urology if symptomatic, right-sided, bilateral, large or associated with subfertility

Epididymal cyst

Smooth, separate from testis, transilluminates. USS if uncertain; reassure if confirmed benign and asymptomatic

Inguinal hernia

Lump extending to groin, reducible lying down, cough impulse. Elective referral if uncomplicated; emergency if irreducible, vomiting or abdominal pain

Testicular malignancy

Non-painful enlargement or change in shape or texture of the testis → consider a suspected cancer pathway referral (NICE NG12); a solid intratesticular lesion on USS → suspected cancer pathway referral. An acutely painful mass needs emergency assessment for torsion, trauma or infection first

Referred pain

Renal/ureteric colic, inguinal hernia, ilioinguinal/genitofemoral nerve, lumbar radiculopathy, hip. Scrotal examination often normal — examine abdomen, loins, back and hips

Prostatitis / CPPS

Perineal/testicular pain with LUTS or ejaculatory pain, often without infection — see Step 10

Chronic scrotal pain (orchialgia)

Persistent or recurrent pain ≥3 months after urgent pathology, malignancy and treatable infection have been considered — see Steps 9–10

Classification determines the management pathway. Torsion cannot be excluded by any single finding, so diagnostic uncertainty means emergency assessment. Epididymo-orchitis has two microbiological pathways (sexually acquired vs enteric) requiring different antibiotics — choose by risk factors, not age alone. A solid intratesticular lesion on USS needs suspected cancer pathway referral; NICE NG12 recommends considering this route for non-painful enlargement or change in shape or texture of the testis. Right-sided varicocele should prompt USS to exclude a renal/retroperitoneal mass.

Diagnose

Step 4 — Targeted Examination

Done

Examine standing and supine. Ensure privacy; offer a chaperone and document the offer.

Observations

Temp, HR, BP, RR, SpO₂ and sepsis assessment. Fever + tachycardia → severe epididymo-orchitis / Fournier's gangrene → escalate urgency

Abdomen & inguinal

Abdomen and renal angles (referred pain). Inguinal canals and hernial orifices, cough impulse → hernia. Lymphadenopathy → infection, malignancy

Scrotal skin

Erythema, oedema, necrosis, bullae or crepitus → Fournier's gangrene (emergency). Scrotal oedema/erythema → epididymo-orchitis. Skin changes → dermatitis, infection

Testicular position

Position and lie: high-riding or horizontal testis increases concern for torsion. A normal testicular position does not exclude torsion

Cremasteric reflex

Document as one finding only. An absent cremasteric reflex, high or horizontal testis, sudden pain, nausea/vomiting and marked testicular tenderness increase concern for torsion, but no single examination finding reliably excludes or confirms torsion. A preserved reflex does not exclude torsion

Testis, epididymis & cord

Testicular size, consistency, focal masses and tenderness. Distinguish the testis from an extratesticular swelling. Epididymal tenderness posteriorly → epididymitis. Palpate the spermatic cord. Do not use Prehn's sign to exclude torsion. It is unreliable.

Transillumination

Torch in dark room → glows red → hydrocele or epididymal cyst. Does not transilluminate → solid lesion or haematocele

Varicocele

Assess standing and supine: dilated veins standing that reduce lying → varicocele (left side predominant). Right-sided or non-reducing → imaging

Referred pain

Neurological, hip and lumbar assessment when referred pain is suspected

DRE

Only when clinically indicated, e.g. suspected prostatitis or significant LUTS

No single sign is diagnostic of torsion: an absent cremasteric reflex raises concern, but a present reflex or normal testicular position does not exclude it. Prehn's sign (historically taught as differentiating epididymitis from torsion) is unreliable and should not alter management. Transillumination is a key clinical skill — a glowing swelling almost always reflects a benign fluid collection. Fournier's gangrene is a life-threatening necrotising fasciitis of the perineum — even mild skin changes with systemic upset warrant immediate escalation.

Diagnose

Step 5 — Investigations

Done

Do not arrange or await investigations — including ultrasound — when clinical suspicion of torsion is high. For suspected epididymo-orchitis, take samples before antibiotics where this will not delay treatment.

Urinalysis + MSU 1st line

Urine dipstick. MSU for culture and sensitivities where urinary/enteric infection is possible. Positive nitrites/leucocytes → uropathogen more likely. Negative doesn't exclude STI-related disease

NAAT swab 1st line STI

First-pass urine (or appropriate) NAAT for Chlamydia trachomatis + Neisseria gonorrhoeae. Consider urethral microscopy/swab if discharge is present and available through sexual health services

Scrotal USS Doppler Only if stable

Do not arrange or await USS when clinical suspicion of torsion is high. If torsion is possible but not clinically clear and the patient is stable, an urgent Doppler USS may assist, provided this does not delay surgical review. A negative ultrasound does not reliably exclude intermittent torsion or torsion in an equivocal case

Tumour markers Per local pathway

Do not delay urgent urology referral for tumour markers. If a testicular malignancy is suspected, AFP, β-hCG and LDH may be requested according to the local pathway, ideally before definitive treatment. Normal markers do not exclude testicular cancer. Not routine for every scrotal lump

FBC, CRP, U&E, blood cultures

If systemically unwell (usually in hospital). Not routine for mild presentations

STI screen

Offer HIV and syphilis testing where an STI is suspected or confirmed. Consider hepatitis B/C testing according to sexual and injecting-risk history

Lump or persistent/unexplained symptoms

Consider urgent direct-access scrotal USS (NICE NG12). Consider a suspected cancer pathway referral to urology for non-painful testicular enlargement or change in shape/texture (NICE NG12); refer a suspicious intratesticular lesion on that pathway — see Scrotal Lumps and Swelling

Uropathogen confirmed

Particularly with recurrent infection or a urinary tract abnormality → arrange urological assessment to exclude obstruction or structural disease (BASHH)

Do not routinely include

PSA during acute prostatitis or active epididymo-orchitis. Testosterone, LH/FSH, fasting glucose or ESR for uncomplicated acute scrotal pain. CT/MRI as first-line. Semen analysis after a single episode — reserve for fertility concerns, bilateral disease or persistent concerns

Colour Doppler ultrasound has a user-dependent false-negative rate, so clinical suspicion overrides a "normal" scan (BASHH). NAAT is needed because culture alone misses Chlamydia. NICE NG12 recommends considering a suspected cancer pathway referral for a non-painful enlargement or change in shape or texture of the testis, and considering direct-access ultrasound for unexplained or persistent testicular symptoms. Tumour markers help staging after referral but must never delay it.

Refer

Step 6 — Referral Criteria and Pathways

Done

Emergency transfer / 999

Suspected torsion (any age) — immediate transfer via the local emergency pathway to a service able to assess and operate; 999 ambulance if haemodynamically unstable, severely unwell or unable to transfer safely. Sepsis or haemodynamic instability. Fournier's gangrene. Incarcerated inguinal hernia. Trauma with suspected rupture. Severe acute pain where torsion cannot be confidently excluded (including uncertain appendage torsion)

Same-day hospital

Severe pain or vomiting preventing oral treatment. Suspected abscess or infarction. Immunocompromise with significant infection. Failure to improve after 48–72 h — reconsider torsion (emergency transfer if it cannot be excluded). Sepsis, haemodynamic instability, Fournier's gangrene or torsion not excluded → emergency transfer / 999, not same-day

Suspected cancer: urology

Non-painful enlargement or change in shape or texture of the testis → consider (NICE NG12). Solid intratesticular lesion on USS → refer. Unexplained or persistent testicular symptoms → consider urgent direct-access USS (NICE NG12)

Urology

Urgent: episodes suggesting intermittent torsion; confirmed uropathogen with recurrent infection or urinary tract abnormality. Routine: varicocele if symptomatic, right-sided, bilateral, large or with subfertility; large symptomatic hydrocele; epididymal cyst requiring treatment; chronic scrotal pain that is persistent, disabling, post-vasectomy, associated with varicocele or not responding to initial measures

Sexual health

Refer or discuss for: gonorrhoea risk or urethral discharge, positive NAAT, partner notification, contact tracing, test of cure for confirmed gonorrhoea where indicated (not routine for ceftriaxone-susceptible anogenital infection treated with ceftriaxone 1 g — BASHH 2025), suspected or confirmed Mycoplasma genitalium. Mixed STI/enteric risk → discuss with sexual health/microbiology

Physiotherapy / pain service

Pelvic-floor physiotherapy for pelvic-floor overactivity, trigger points or CPPS features. Pain service for neuropathic pain, significant disability, sleep disturbance, psychological comorbidity or failed conservative treatment

Primary care manage

Uncomplicated epididymo-orchitis responding to treatment. Confidently diagnosed appendage torsion. Confirmed benign, asymptomatic hydrocele or epididymal cyst. Asymptomatic small varicocele in men not seeking fertility

Torsion is time-critical — use the local emergency pathway; for children and young people the GIRFT pathway supports immediate referral to a centre able to provide surgical exploration. Suspected cancer referral criteria follow NICE NG12. Sexual-health services provide partner notification, contact tracing and test of cure where indicated, preventing reinfection and onward transmission. Recurrent uropathogen epididymo-orchitis may indicate obstruction or structural urinary tract disease (BASHH).

Treat

Step 7 — Acute Treatment by Presentation

Done

Treat epididymo-orchitis by likely pathogen using risk factors, not age alone. Follow current BASHH, local sexual-health and antimicrobial guidance.

Likely sexually acquired

Ceftriaxone + Doxycycline Sexual health

Ceftriaxone 1 g IM single dose + doxycycline 100 mg BD PO for 10–14 days (BASHH 2020). Use the local sexual-health pathway and gonorrhoea guidance. Avoid fluoroquinolones (gonorrhoea resistance). No sexual contact until treatment completed, symptoms improved and partners assessed/treated per sexual-health advice

Likely enteric / uropathogen

Per BASHH / local guideline MSU first

Consider with positive urine leucocytes/nitrites, older age with low STI risk, recent urinary instrumentation or catheterisation, urinary tract abnormality or obstruction, recent urological procedure, or no STI features — not age alone. Send MSU before treatment where possible; follow the local antimicrobial guideline and susceptibilities (BASHH 2020 lists ofloxacin 200 mg BD for 14 days, or levofloxacin 500 mg once daily for 10 days, when enteric organisms are likely). MHRA (January 2024): use a systemic fluoroquinolone only when other commonly recommended antibiotics are inappropriate, taking account of microbiology, contraindications, resistance, previous treatment and local advice. Tell patients to stop and seek advice if tendon pain/swelling, neuropathic symptoms, marked muscle or joint symptoms, severe mood change, confusion or other serious adverse effects

Analgesia (all)

Give promptly

Analgesia must not delay urgent referral. Paracetamol, if appropriate. NSAID (e.g. ibuprofen 400 mg TDS with food) only after assessing renal, gastrointestinal, cardiovascular, anticoagulant and other contraindications. Scrotal support/elevation. Local cooling — avoid direct ice contact with skin

Mixed STI + enteric risk

Discuss first Sexual health / micro

e.g. insertive anal intercourse with STI risk. Discuss with sexual health/microbiology: ceftriaxone plus an agent covering enteric organisms may be required according to current BASHH/local guidance — not an automatic primary-care prescription; consider fluoroquinolone safety

Severe illness

Same-day hospital IV treatment

Severe pain or vomiting preventing oral treatment, suspected abscess/infarction, immunocompromise with significant infection, or failure to improve after 48–72 h. Sepsis/haemodynamic compromise or suspected Fournier's → 999; torsion not excluded → emergency transfer (Step 1)

HydroceleUltrasound if uncertain or testis not examinable; reassure if confirmed benign and asymptomatic. Refer urology if large or symptomatic

VaricoceleSupportive treatment (scrotal support, analgesia). Urology if symptomatic, right-sided, bilateral, large or associated with subfertility. Surgical or radiological embolisation in secondary care

Epididymal cystReassure if USS confirmed benign. No GP treatment required. Refer urology if symptomatic for excision

Suspected torsionImmediate emergency transfer; no delay for USS

Appendage torsionConfident diagnosis: analgesia, support and safety-net; immediate emergency surgical assessment if uncertain or worsening

Chronic painExclude structural disease; multimodal pain, pelvic-floor and urology pathway — see Steps 9–10

BASHH (2020) recommends ceftriaxone plus doxycycline for likely sexually acquired epididymo-orchitis; ceftriaxone covers gonorrhoea, in which fluoroquinolone resistance is common. The 2024 European guideline cautions against using age as a surrogate for STI risk, so choose the regimen from sexual and urinary risk factors. The MHRA (January 2024) restricts systemic fluoroquinolones to situations where other commonly recommended antibiotics are inappropriate because of disabling and potentially long-lasting adverse effects — do not prescribe ciprofloxacin generically for all patients. The local antimicrobial guideline is the operational antibiotic reference for GP use.

Lifestyle

Step 8 — Supportive Care & Prevention

Done

Analgesia Give promptly; paracetamol if appropriate; NSAID only after checking renal, GI, cardiovascular and anticoagulant contraindications. Do not exceed the maximum daily dose

Scrotal support / elevation Supportive underwear or jockstrap. May ease pain in epididymo-orchitis, varicocele and chronic scrotal pain

Sexual health No sexual contact until treatment completed, symptoms improved and partners assessed/treated. Condom use. Sexual-health services for partner notification and STI prevention advice

Testicular awareness Know what is normal. Report any new lump, swelling or change in shape or texture promptly

Rest & activity modification Rest and avoid heavy lifting during the acute phase. Resume activity gradually as pain settles

Local cooling May help acute inflammatory pain. Wrap cold packs — avoid direct ice contact with skin

Fertility Semen analysis and fertility advice only for fertility concerns, bilateral disease or persistent concerns — not routinely after a single episode. Sperm banking discussion before cancer treatment

Smoking cessation Smoking impairs sperm quality and testicular blood flow. Offer referral to NHS Stop Smoking service

Alcohol reduction Excess alcohol impairs spermatogenesis. AUDIT-C score; brief intervention if score ≥5

Supportive measures relieve symptoms while antibiotics act. Testicular self-examination is not recommended as a population screening tool, but awareness of what is normal helps men present promptly with a new lump. Semen analysis is not routine after a single episode of epididymo-orchitis; reserve it for fertility concerns, bilateral disease or persistent concerns. Men diagnosed with testicular cancer should be offered sperm banking before treatment. Partner notification and treatment reduce reinfection and onward transmission.

Diagnose

Step 9 — Chronic Scrotal Pain (≥3 Months): Define & Exclude

Done

Persistent or recurrent scrotal/testicular pain for at least 3 months that affects function, sleep, sexual activity or quality of life, after urgent pathology, malignancy and treatable infection have been considered.

Exclude first

Torsion, including intermittent torsion. Testicular malignancy. Epididymo-orchitis or abscess. Hernia. Varicocele. Hydrocele or epididymal cyst. Post-operative/inguinal nerve pain. Renal colic. Lumbar radiculopathy. Hip or pelvic-floor pathology. Chronic pelvic pain syndrome

Terminology

The EAU uses primary scrotal pain syndrome or primary testicular pain syndrome when there is no proven infection or other local pathology. "Chronic orchialgia" remains understandable clinically but is a descriptive term, not a formally specific disease

History

Vasectomy, hernia repair (ilioinguinal nerve), previous epididymo-orchitis, trauma. LUTS or pain on ejaculation (prostatitis/CPPS). Back, hip or groin pain. Prolonged sitting or cycling. Treatments already tried

Impact

Document pain severity (e.g. 0–10 scale) and functional impact on sleep, work, sexual function and mood. Review sexual, urinary, bowel, musculoskeletal and psychosocial factors, including cancer worry

Examination

As Step 4, plus inguinal tenderness after hernia repair, groin/inner-thigh sensation, lumbar spine and hip, pelvic-floor and trigger-point tenderness. DRE only if prostatitis or significant LUTS

Ultrasound

Consider urgent direct-access scrotal ultrasound (NICE NG12) for unexplained or persistent testicular symptoms, a new lump, uncertain examination or where the testis cannot be adequately assessed. Do not routinely repeat ultrasound when a recent high-quality scan is normal and there has been no change in examination or symptoms

Normal ultrasound

Excludes many structural lesions but does not exclude chronic pain, neuropathic pain, pelvic-floor dysfunction or intermittent torsion

Other tests

Urinalysis, MSU and NAAT if infection is possible. Imaging for referred pain (e.g. renal tract, lumbar spine) only when clinically suspected. Suspected chronic bacterial prostatitis → obtain appropriate cultures and seek urological/microbiological advice

Chronic scrotal pain should only be labelled after structural, malignant, infective and referred causes have been considered — but it should not be presented as a formally specific disease (EAU chronic pelvic pain guidance). Ultrasound is not mandatory in every man and will often be normal; it excludes structural pathology, while repeated normal scans can reinforce reassurance-seeking without changing management.

Treat

Step 10 — Chronic Scrotal Pain: Multimodal Management

Done

The central message is multimodal management, not repeated antibiotic or analgesic prescribing.

Explain

Explain the diagnosis and that cancer has been excluded, without reinforcing repeated reassurance-seeking. Set realistic, function-based goals

Self-management

Scrotal support and activity modification where helpful. Simple analgesia by shared decision-making — regular use is not necessarily better than as-required; never exceed the maximum daily dose

Physical activity & psychology

NICE NG193 prioritises physical activity and psychological therapies (e.g. CBT, ACT) for chronic primary pain

Physiotherapy

Pelvic-floor physiotherapy if pelvic-floor overactivity, trigger-point tenderness or CPPS features. Physiotherapy for post-hernia-repair or musculoskeletal pain

Urology

If pain is persistent, disabling, post-vasectomy, associated with varicocele or not responding to initial measures. Nerve blocks or surgical options are specialist decisions

Pain service

Neuropathic pain, significant disability, sleep disturbance, psychological comorbidity or failed conservative treatment

Neuropathic phenotypeOnly if convincing: cautious off-label trial using general neuropathic-pain guidance (NICE CG173) — amitriptyline 10 mg at night, titrated cautiously by response and tolerability; or gabapentin, pregabalin or duloxetine depending on comorbidity, interactions and local formulary

ReviewReview benefit, function and adverse effects within an agreed timeframe. Avoid routine combination of neuropathic-pain medicines in primary care. Taper rather than stop abruptly when clinically appropriate

CautionsGabapentin/pregabalin: renal dosing, misuse/dependence assessment, controlled-drug prescribing requirements. Amitriptyline: avoid or use great caution in older adults, cardiac conduction disease, glaucoma, urinary retention and substantial anticholinergic burden

Primary painDo not initiate NSAIDs, opioids, paracetamol or gabapentinoids solely for chronic primary pain (NICE NG193)

AntibioticsDo not prescribe prolonged antibiotics (including fluoroquinolones) for CPPS without evidence of bacterial infection

TamsulosinNot routine for testicular pain. Consider only with significant LUTS and a prostate-pain/CPPS phenotype; review benefit

Next steps: see Varicocele · Hernia · Chlamydia · Gonorrhoea · Chronic primary pain

NICE CG173 supports offering a choice of amitriptyline, duloxetine, gabapentin or pregabalin for neuropathic pain in general — this is not high-quality evidence specifically for chronic orchialgia. For chronic primary pain, NICE NG193 prioritises physical activity and psychological therapies and advises against initiating NSAIDs, opioids, paracetamol or gabapentinoids solely for chronic primary pain. The EAU chronic pelvic pain guidance supports a multimodal, phenotype-directed approach.

Safety

Step 11 — Follow-Up, Monitoring & Safety-Netting

Done

48–72h review

Review acute epididymo-orchitis response and microbiology (MSU / NAAT). Not improving → same-day hospital assessment; reconsider torsion, abscess or the wrong organism

1–2 week review

Assess pain, swelling, fever, treatment adherence and sexual-health follow-up (partner notification; gonorrhoea test of cure where indicated — BASHH 2025)

Persistent swelling / poor response

Persistent swelling, mass or poor response → urgent ultrasound and/or urology review (a tumour can co-exist with or be masked by infection)

Safety-net — emergency

New acute severe pain at any time → emergency assessment again, even with a history of chronic orchialgia (torsion). Scrotal skin necrosis, blistering or crepitus with feeling very unwell (Fournier's). Collapse, haemodynamic instability

Safety-net same-day

Fever not settling after 48–72 h of antibiotics. Increasing swelling despite treatment. New systemic symptoms. Unable to tolerate oral antibiotics. On a fluoroquinolone: stop and seek advice if tendon pain/swelling, neuropathic symptoms, marked muscle or joint symptoms, severe mood change or confusion

Fertility follow-up

Semen analysis only for fertility concerns, bilateral disease or persistent concerns — not routinely after a single episode. Refer fertility services if abnormal

Suspected cancer safety net

Any new non-painful enlargement or change in shape or texture of the testis → consider a suspected cancer pathway referral or urgent direct-access USS (NICE NG12), regardless of a previous normal scan

Chronic scrotal pain

Structured review of function, sleep, sexual function, mood, medicine benefit and adverse effects at agreed intervals. Refer urology/pain service if not improving. Avoid indefinite repeat prescriptions without review

Early review detects non-response, abscess formation or a missed alternative diagnosis. Persistent swelling must trigger USS because testicular tumours can present sub-acutely and may initially appear as "epididymo-orchitis". Patients with chronic scrotal pain can still develop torsion or other acute pathology — new acute severe pain needs fresh emergency assessment. Clear written safety-netting on when to seek emergency help is a patient safety imperative and RCGP examination competency.