Emergency Care Institute – Clinical tools

Acute scrotum

Published: June 2016. Minor revision: March 2026. Minor revision: July 2026. Next review: 2031. Printed on 7 Oct 2026.

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Acute scrotum is defined as an acutely painful, swollen scrotum or its contents. It makes up <1% of ED presentations. Not only can the acute scrotum pose a threat to the patient’s future fertility, but it can also have significant psychological implications, making it a highly sensitive and anxiety-provoking presentation for both the patient and clinician.

The three most common causes of acute scrotal pain are:

  • testicular torsion
  • torsion of testicular appendage
  • epididymo-orchitis.

It is imperative that any life- or fertility-threatening condition is considered and ruled out. These include testicular torsion, incarcerated hernia and Fournier’s gangrene.

Paediatric resources

Clinical practice guidelines: Acute scrotal pain or swelling
Source: Paediatric Improvement Collaborative

Acute scrotal pain and suspected testicular torsion guidelines
Source: Royal Australasian College of Surgeons

Assessment

Any acute scrotum should be triaged as category 2.

A suspected testicular torsion should be escalated to a senior medical officer to consider an immediate surgical review for urgent diagnostic and therapeutic exploration in theatre.

History

  • Pain – location, time of onset, intensity, radiation
  • Associated symptoms – nausea, vomiting, urinary symptoms, fevers
  • History of trauma
  • Sexual history
  • Past medical history and co-morbidities, such as diabetes or immunosuppression

General examination

  • Vital signs (fever, tachycardia). Escalate as per CERS protocol, if required
  • Abdominal exam (inguinal hernia, referred pain)

Scrotal examination

Compare both sides:

  • Testicular position (high riding, transverse lie)
  • Tenderness (testis vs epididymis)
  • Swelling, erythema, skin changes
  • Cord tenderness
  • Cremasteric reflex (absence is concerning but not diagnostic)
  • Palpable mass or fluctuance

Note: Prehn’s sign is not reliable and should not guide management.

Acute scrotal and groin pathologies

Key clinical features
  • Sudden, severe unilateral pain
  • High‑riding or horizontal testis
  • Absent cremasteric reflex (late)
  • Nausea and/or vomiting is common
Intervention
  • Treat as torsion until proven otherwise
  • Urgent urological and/or surgical referral
  • Appropriate analgesia
  • Keep nil-by-mouth (NBM)
  • Obtain consent and prepare for theatre
Definitive management
  • Immediate surgical exploration
  • Manual detorsion. May attempt only if there is a surgical delay and skilled operator. Does NOT replace surgery
  • Requires bilateral orchidopexy

Key clinical features
  • Gradual onset of pain
  • Epididymal tenderness and/or swelling
  • Possible dysuria, frequency, or sexually-transmitted infection risk
  • Cremasteric reflex usually preserved
Intervention
  • Analgesia (non-steroidal anti-inflammatory drugs with or without opioids)
  • Scrotal support and elevation
Definitive management

For antibiotic management refer to:
Epididymo-orchitis
Source:  Therapeutic Guidelines

Key clinical features
  • History of blunt or penetrating injury
  • Pain, swelling, bruising
Intervention
  • Analgesia
  • Scrotal support
  • Ultrasound if there is concern for internal injury
Definitive management
  • Minor trauma: conservative management
  • Suspected rupture or expanding haematoma: urgent urology review

Key clinical features
  • Groin or scrotal mass
  • Painful lump
  • Obstructive symptoms with or without systemic signs
Intervention
  • Assess for strangulation
Definitive management
  • Incarcerated and/or strangulated: urgent surgical review
  • Gentle reduction only if NO signs of strangulation

Key clinical features
  • Severe pain, out of proportion
  • Systemic toxicity
  • Crepitus, skin necrosis, dusky skin
Intervention
Definitive management
  • Emergency surgical debridement
  • Consider ICU

Resources

References

  • Barada JH, Weingarten JL, Cromie WJ. Testicular salvage and age-related delay in the presentation of testicular torsion. J Urology 1989;142:746-8
  • Ciftci AO, Senocak ME, Tanyel FC, et al. Clinical predictors for differential diagnosis of acute scrotum. Scan J Paed Surg 2004;15(5):333-8
  • Cokkinos DD, Antypa E, Tserotas P, et al. Emergency ultrasound of the scrotum: a review of the commonest pathological conditions. Curr Probl Diagn Radiol 2011;40:1-14
  • Davenport M. ABC of general surgery in children. Acute problems of the scrotum. BMJ 1996;312:435-437
  • Davis JE, Silverman, M. Scrotal Emergencies. Emerg Med Clin N Am 29 (2011) 469-484
  • Jefferson RH, Perez LM, Joseph DB. J Urol. 1997;158:1198-1200.
  • Kuo CF, Wang WS, Lee CM, et al. Fournier’s Gangrene: ten year experience in a medical centre in northern Taiwan. J Microbiol Immunol Infect 2007 Dec;40(6):500-6
  • Liang T, Metcalfe P, Sevcik W, et al. Retrospective review of diagnosis and treatment of children presenting to the paediatric department with Acute Scrotum. AJR:200 May 2013
  • Mellick LB. Torsion of the testicle: it is time to stop tossing the dice. Pediatr Emerg Care. 2012 Jan;28(1):80-6. DOI: 10.1097/PEC.0b013e31823f5ed9.
  • Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006 Nov 15;74(10):1739-43.
  • Tintinalli, JE, Kelen GD, Stapczynski JS et al. Emergency Medicine: A Comprehensive Study guide. 6th Ed. New York: McGraw-Hill; 2004.
  • Verma S, Sayana A, Kala S, et al. Evaluation of the Utility of the Fournier’s Gangrene Severity Score Index in the Management of Fournier’s Gangrene in North India: A Multicentre Retrospective Study. J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 273-276

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/networks/eci/clinical/tools/acute-scrotum

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