Scrotal Lumps and Testicle Pain: Causes, Warning Signs and Treatment

By Mr Neil Haldar, Consultant Urological Surgeon

Clinically reviewed: July 2026

Most lumps found in the scrotum are benign. Common causes include epididymal cysts, hydroceles and varicoceles. However, a new hard lump arising from within the testicle itself must be assessed promptly to exclude testicular cancer.

Sudden, severe testicle pain is an emergency because it may be caused by testicular torsion, in which the spermatic cord twists and cuts off the blood supply to the testis. The chance of preserving the testicle is greatest when treatment takes place within the first few hours.

A clinical examination and scrotal ultrasound can usually distinguish a harmless swelling from a condition requiring treatment. Ultrasound is extremely useful for investigating a lump or persistent discomfort, but it should not delay surgery when testicular torsion is strongly suspected.

Seek emergency help now

Attend your nearest emergency department immediately if you or your child develops:

sudden, severe pain in one testicle;

testicular pain associated with nausea or vomiting;

rapidly increasing scrotal swelling;

severe pain following testicular trauma;

a painful groin or scrotal swelling that cannot be pushed back;

fever, severe illness or rapidly spreading redness or discolouration of the scrotal skin.

Do not wait for a routine GP or private clinic appointment if the pain is sudden and severe. Do not eat or drink in case an urgent anaesthetic is required.

What causes a lump or pain in the scrotum?

A lump in the scrotum can arise from several different structures. Some are part of the testicle itself, while others develop in the tissues surrounding it.

The most important distinction is whether a lump is:

intratesticular, meaning that it arises from within the body of the testicle; or
extratesticular, meaning that it arises beside or around the testicle.

Most extratesticular lumps are benign. A solid intratesticular lump is more concerning and should be treated as a possible testicular tumour until proven otherwise.

Scrotal pain can also have many causes. These range from inflammation and infection to nerve pain, trauma, hernia, kidney stones and testicular torsion.

Common scrotal conditions at a glance

Condition	Typical features	Is it painful?	How urgently should it be assessed?
Epididymal cyst	Smooth lump above or behind the testicle, separate from it	Usually painless	Routine or prompt assessment
Hydrocele	Smooth fluid swelling surrounding the testicle	Usually painless or heavy	Routine or prompt assessment
Varicocele	Soft “bag of worms” above the testicle, more obvious when standing	May cause a dragging ache	Routine assessment
Testicular tumour	Hard lump or change within the body of the testicle	Often painless	Prompt urgent assessment
Testicular torsion	Sudden, severe pain, often with nausea or vomiting	Severe	Immediate emergency assessment
Epididymo-orchitis	Increasing pain, swelling, redness and sometimes urinary symptoms	Usually painful	Prompt assessment
Inguinoscrotal hernia	Groin swelling extending into the scrotum	Variable	Emergency if painful and irreducible
Chronic scrotal pain	Persistent or recurring discomfort for at least three months	Variable	Specialist assessment

Understanding the anatomy of the scrotum

Working out where a lump has come from is central to making the correct diagnosis.

The testicle

The testicle, or testis, produces sperm and testosterone. A normal adult testicle should feel smooth, firm and relatively uniform.

A hard or irregular lump that appears to arise from within the body of the testicle requires prompt investigation. It may not be cancer, but testicular cancer must be excluded.

The epididymis

The epididymis is a long, coiled tube that lies behind and above the testicle. It stores and transports sperm.

It is a common site of benign cysts and inflammation. Men frequently mistake the normal epididymis for a lump because it feels different from the smooth surface of the testicle.

An epididymal cyst can usually be felt separately from the testicle, which is generally a reassuring sign.

The spermatic cord

The spermatic cord runs from the testicle towards the groin. It contains:

the vas deferens;
the testicular artery;
veins draining the testicle;
lymphatic vessels;
nerves.

Enlargement of the veins within the cord produces a varicocele. Twisting of the cord causes testicular torsion.

The tunica vaginalis

The tunica vaginalis is a thin membrane surrounding much of the testicle. Fluid collecting within this space produces a hydrocele.

The scrotal skin

The skin of the scrotum contains hair follicles, sweat glands and sebaceous glands. It can develop harmless superficial lesions such as epidermoid cysts, inflamed follicles and areas of calcification.

When testicle pain is an emergency

Testicular torsion

Testicular torsion occurs when the spermatic cord twists, reducing or completely stopping blood flow to the testicle.

It is most common during adolescence and in newborn babies, but it can occur at any age.

The pain typically begins suddenly and is often severe. It may wake someone from sleep or start during exercise, although it can also occur without any obvious trigger.

Typical symptoms include:

sudden pain in one testicle;
rapid swelling;
nausea or vomiting;
lower abdominal or groin pain;
a testicle sitting higher than usual;
a testicle lying at an unusual horizontal angle;
redness of the scrotum.

The chance of preserving the testicle is greatest when the cord is untwisted within approximately four to six hours. The likelihood of permanent damage increases rapidly as time passes, although the outcome also depends on how tightly the cord has twisted.

Can an ultrasound exclude testicular torsion?

Ultrasound can be helpful when the diagnosis is uncertain, but apparently preserved blood flow does not always exclude early, partial or intermittent torsion.

When the clinical suspicion is high, urgent surgical exploration should not be delayed by an apparently reassuring scan.

Intermittent testicular torsion

Some boys and men experience repeated episodes of severe testicular pain that resolve spontaneously after several minutes or hours.

This may represent torsion followed by spontaneous detorsion. The pain improves because the cord has untwisted, but the underlying anatomical predisposition remains.

Intermittent torsion should not be dismissed. Surgical fixation may be advised because a future episode may not resolve spontaneously.

Fournier’s gangrene

Fournier’s gangrene is a rare but life-threatening infection affecting the tissues of the scrotum, perineum and surrounding areas.

It is more likely to occur in men with conditions such as:

diabetes;
obesity;
impaired immunity;
severe systemic illness;
recent perineal surgery or infection.

Warning signs include:

severe pain, sometimes out of proportion to the early appearance;
fever or systemic illness;
rapidly spreading swelling or redness;
purple or black skin discolouration;
foul-smelling discharge;
a crackling sensation beneath the skin.

Treatment requires emergency resuscitation, intravenous antibiotics and urgent surgery to remove infected tissue.

Significant testicular trauma

A direct blow to the scrotum can cause bruising, bleeding or rupture of the testicle.

Marked swelling, severe persistent pain, loss of the normal shape of the testicle or extensive bruising should be assessed urgently.

Suspected rupture usually requires urgent ultrasound and early surgical exploration. Early repair offers the best chance of preserving the testicle.

Strangulated inguinoscrotal hernia

An inguinal hernia occurs when abdominal tissue, often bowel, pushes through the groin. A large hernia can descend into the scrotum.

Emergency assessment is required if the swelling:

becomes acutely painful;
cannot be pushed back;
is associated with vomiting;
is associated with abdominal swelling;
is accompanied by inability to pass stool or wind.

These symptoms may indicate that the blood supply to the bowel has become compromised.

Common causes of a scrotal lump

Epididymal cysts and spermatoceles

Epididymal cysts are among the commonest benign scrotal lumps.

They are fluid-filled swellings arising from the epididymis, usually above or behind the testicle. A spermatocele is a similar cyst containing sperm-rich fluid.

They typically feel:

smooth;
mobile;
separate from the body of the testicle;
painless or only mildly uncomfortable.

They may occur on one or both sides and can be single or multiple. Some remain extremely small, while others gradually enlarge over several years.

Are epididymal cysts dangerous?

A confirmed epididymal cyst is benign and does not turn into testicular cancer.

Most require no treatment once the diagnosis has been confirmed. Ultrasound is often used when the diagnosis is uncertain or when a man has found a new lump.

When should an epididymal cyst be removed?

Surgery may be considered when a cyst:

causes persistent discomfort;
becomes large or cumbersome;
interferes with sport, sitting or clothing;
creates unacceptable cosmetic concern.

Surgery involves operating close to the epididymis and can cause scarring or obstruction of sperm transport on that side.

For that reason, I am particularly cautious about recommending surgery to younger men who have not completed their families. The balance between symptoms, fertility and the likely benefit of surgery should be discussed carefully.

Hydrocele

A hydrocele is a collection of fluid surrounding the testicle.

It usually presents as a smooth, painless swelling that may feel heavy or inconvenient. The swelling can become large enough to affect walking, exercise, clothing or sexual activity.

Because the fluid surrounds the testicle, the testicle may be difficult or impossible to feel separately.

Does a new hydrocele require ultrasound?

I usually arrange an ultrasound for a new adult hydrocele, particularly when:

the testicle cannot be examined properly;
the swelling has appeared recently;
it has enlarged;
it is painful;
there is any diagnostic uncertainty.

The purpose is to confirm that the testicle hidden within the fluid is normal and to exclude an underlying testicular abnormality, inflammation, trauma or tumour.

Does a hydrocele always need treatment?

No. A small, painless hydrocele can often be observed.

Treatment may be considered if it is:

uncomfortable;
progressively enlarging;
interfering with normal activity;
causing difficulty with clothing;
cosmetically troublesome.

Hydrocele surgery

Surgical treatment involves opening or removing part of the sac responsible for containing the fluid.

Common techniques include:

Lord’s plication;
Jaboulay eversion;
partial excision of the hydrocele sac.

The most appropriate technique depends on the size and thickness of the hydrocele.

Aspiration removes the fluid but leaves the sac behind. It therefore has a high recurrence rate and is not usually recommended as a definitive treatment in men fit for surgery.

Aspiration with sclerotherapy may be considered in selected men who are unable or unwilling to undergo an operation.

Hydroceles in babies and children

Hydroceles in babies are often caused by persistence of the processus vaginalis, a channel between the abdomen and scrotum that normally closes around the time of birth.

A communicating hydrocele may fluctuate in size. It can appear larger later in the day or after activity and smaller after lying down overnight.

Many infant hydroceles resolve spontaneously and can initially be observed.

Specialist paediatric assessment is appropriate if the hydrocele:

persists;
progressively enlarges;
is associated with an inguinal hernia;
causes discomfort;
raises concern about the underlying testicle.

The timing of surgery depends on the child’s age, symptoms, examination findings and whether a communicating channel or hernia is present.

Varicocele

A varicocele is an enlargement of the veins that drain the testicle. It is similar to the development of varicose veins in the leg.

It often feels like a soft “bag of worms” above and behind the testicle.

The swelling is usually:

more obvious when standing;
more prominent when coughing or straining;
less noticeable when lying flat.

Varicoceles occur much more commonly on the left because of the way the left testicular vein drains into the abdominal venous system.

What symptoms does a varicocele cause?

Many varicoceles cause no symptoms.

When discomfort occurs, it is usually described as:

a dull ache;
heaviness;
dragging;
discomfort after exercise;
pain after prolonged standing;
pain that is worse towards the end of the day.

Can a varicocele affect fertility?

Most men with a varicocele are fertile. However, varicoceles are more common among men being investigated for reduced fertility and may be associated with impaired sperm quality in some cases.

Treatment may be considered when a man has:

a clinically detectable varicocele;
abnormal semen analysis;
fertility difficulties;
troublesome persistent pain.

In adolescents, treatment may be advised if the affected testicle shows reduced growth compared with the other side.

When is a right-sided varicocele concerning?

A new right-sided varicocele, particularly in an older man, may require further investigation if it:

appears suddenly;
does not decompress when lying down;
is associated with abdominal symptoms;
is accompanied by blood in the urine, weight loss or other concerning features.

In these circumstances, abdominal imaging may be advised to exclude an obstruction affecting the venous drainage.

How is a varicocele treated?

Options include:

radiological embolisation;
microsurgical ligation;
other forms of surgical ligation.

The choice depends on symptoms, fertility goals, anatomy, previous surgery and local expertise.

Inguinoscrotal hernia

An inguinal hernia may extend from the groin into the scrotum.

Unlike a swelling confined to the scrotum, the upper border of a hernia may not be palpable because it continues into the inguinal canal.

A hernia may:

become more obvious when standing;
enlarge with coughing or straining;
reduce when lying down;
produce a dragging sensation;
occasionally contain bowel sounds.

Adult inguinal hernias do not resolve spontaneously. Surgery is considered according to symptoms, size and the risk of complications.

A painful hernia that cannot be reduced requires emergency assessment.

Testicular cancer

Testicular cancer is the diagnosis many men fear when they discover a lump. However, it is important to keep the risk in perspective.

Most scrotal lumps are not cancer. Testicular cancer is also among the most treatable cancers, particularly when diagnosed early.

Around 2,300 men are diagnosed with testicular cancer each year in the UK. It occurs most often in younger and middle-aged men, although a new testicular abnormality at any age should be assessed.

What does a testicular tumour feel like?

The classic presentation is a:

hard lump;
irregular area;
change in the texture of the testicle;
painless enlargement of one testicle.

Other possible symptoms include:

a dull ache;
a sensation of heaviness;
discomfort rather than severe pain;
a new hydrocele;
a change in testicular shape;
breast tenderness or enlargement.

Testicular cancer is often painless, but pain does not exclude it.

Who is at increased risk?

Recognised risk factors include:

an undescended testicle;
previous testicular cancer;
a close family history;
reduced fertility;
abnormalities of testicular development.

Correcting an undescended testicle does not eliminate the increased risk entirely, although earlier surgery makes examination and monitoring easier and may reduce some associated risks.

Is testicular cancer curable?

Yes. Overall outcomes are excellent, and cure rates are particularly high when the disease is confined to the testicle.

Early diagnosis usually makes treatment simpler and may reduce the need for chemotherapy or more extensive treatment.

A new hard lump should therefore prompt assessment rather than panic or delay.

Other causes of scrotal lumps

Sperm granuloma

A sperm granuloma is a small inflammatory lump that may develop at the divided end of the vas deferens following vasectomy.

It is benign but can sometimes be tender or contribute to post-vasectomy discomfort.

Epidermoid cysts of the scrotal skin

Epidermoid cysts develop within the scrotal skin rather than inside the scrotum.

They usually move with the skin and may be multiple. They are benign but can become inflamed or infected.

Removal may be considered if they repeatedly become infected or cause cosmetic concern.

Idiopathic scrotal calcinosis

Scrotal calcinosis produces multiple firm, pale or yellowish nodules within the scrotal skin.

The condition is benign. Treatment is usually considered only if the lesions cause discomfort or cosmetic concern.

Adenomatoid tumour

An adenomatoid tumour is the commonest benign solid tumour of the epididymis.

It usually presents as a small, firm, painless nodule. Ultrasound may suggest the diagnosis, although surgical removal may occasionally be advised if there is uncertainty about its nature.

Testicular microlithiasis

Testicular microlithiasis describes tiny deposits of calcium seen within the testicle during ultrasound.

It is an imaging finding rather than a lump that can usually be felt.

In isolation, and without additional risk factors for testicular cancer, it does not generally require repeated surveillance ultrasound. Men should instead be familiar with the normal feel of their testicles and seek assessment if anything changes.

Rare scrotal and paratesticular tumours

Rare causes of a scrotal mass include:

paratesticular sarcoma;
liposarcoma;
lymphoma;
Leydig cell tumour;
Sertoli cell tumour.

In older men, lymphoma becomes a more important potential cause of testicular enlargement and may affect both testicles.

Common causes of testicle pain

Epididymo-orchitis

Epididymo-orchitis is inflammation of the epididymis and sometimes the testicle.

Unlike torsion, which often begins suddenly, epididymo-orchitis more commonly develops over several hours or days.

Symptoms may include:

increasing testicular pain;
swelling;
redness;
fever;
pain when passing urine;
urinary frequency;
urethral discharge;
discomfort during ejaculation.

What causes epididymo-orchitis?

The likely organism depends more on sexual history, urinary symptoms, recent procedures and underlying urinary tract problems than on age alone.

Sexually transmitted infections such as chlamydia and gonorrhoea are more likely when there has been:

a new sexual partner;
unprotected sexual contact;
urethral discharge;
another recognised STI risk.

Enteric bacteria such as Escherichia coli are more likely in men with:

urinary tract infection;
an enlarged prostate or difficulty emptying the bladder;
a urinary catheter;
recent urological instrumentation;
structural urinary tract abnormalities.

Assessment may include urine testing and testing for sexually transmitted infections.

Treatment commonly includes antibiotics, pain relief, rest and scrotal support. Sexual partners may also require assessment and treatment where an STI is identified or suspected.

Failure to improve should prompt reassessment and sometimes repeat imaging to exclude an abscess or another diagnosis.

Mumps orchitis

Mumps can cause inflammation of one or both testicles, particularly in post-pubertal males.

The testicular pain and swelling usually develop several days after swelling of the salivary glands.

Treatment is mainly supportive, using analgesia, rest and scrotal support.

Mumps orchitis can occasionally impair testicular function, particularly when both testicles are affected.

Torsion of the appendix testis

The appendix testis is a small embryological remnant attached near the upper part of the testicle.

It can twist and become painful, particularly in boys aged approximately seven to twelve.

The pain is often less severe than testicular torsion and may be concentrated at the upper pole of the testicle. A small blue or dark spot may occasionally be visible through the scrotal skin.

The condition usually settles with rest and pain relief. However, torsion of the testicle must first be excluded safely.

Referred pain

Not all pain felt in the scrotum begins there.

Possible causes of referred testicle pain include:

a ureteric or kidney stone;
an inguinal hernia;
nerve irritation after hernia surgery;
lower spinal nerve root problems;
hip disease;
pelvic floor muscle tension;
abdominal or retroperitoneal disease.

A normal ultrasound does not mean the pain is not real. It may mean that the source lies outside the testicle or that the discomfort is neuropathic.

Chronic testicular and scrotal pain

Chronic scrotal pain, sometimes called chronic orchialgia or chronic scrotal content pain, generally refers to intermittent or constant pain lasting for at least three months and affecting daily life.

It can be a frustrating condition. Some men receive repeated antibiotics despite having no evidence of infection, while others are told that nothing is wrong because an ultrasound is normal.

Neither approach is satisfactory.

What causes chronic scrotal pain?

Recognised causes include:

previous epididymitis or orchitis;
previous testicular trauma;
varicocele;
inguinal hernia;
nerve injury following hernia repair;
previous pelvic or scrotal surgery;
post-vasectomy pain syndrome;
sperm granuloma;
pelvic floor muscle overactivity;
referred spinal, hip or ureteric pain.

In a substantial proportion of men, no single structural abnormality is identified.

This does not mean the pain is imagined. It may arise from irritation or sensitisation of the nerves supplying the testicle, epididymis and spermatic cord.

Post-vasectomy pain syndrome

Some discomfort is common in the days or weeks after vasectomy.

Post-vasectomy pain syndrome refers to persistent or recurrent testicular or epididymal pain lasting beyond the expected recovery period and affecting quality of life.

Potential mechanisms include:

congestion within the epididymis;
sperm granuloma;
inflammation;
nerve irritation;
scar tissue;
pelvic floor dysfunction.

Treatment depends on the likely source and may include medication, pelvic floor physiotherapy, nerve blocks and, in carefully selected men, surgery.

How are scrotal lumps and testicle pain investigated?

Clinical history

The consultation begins by establishing:

when the lump or pain began;
whether it appeared suddenly or gradually;
whether the symptoms are changing;
whether there was trauma;
whether urinary symptoms are present;
whether there is any urethral discharge;
whether there are fertility concerns;
whether there has been previous scrotal, groin or pelvic surgery;
whether the swelling changes with posture or activity.

The pattern of symptoms often helps distinguish torsion, infection, hernia, varicocele and chronic nerve-related pain.

Physical examination

The examination assesses:

whether the lump is within or separate from the testicle;
whether it is solid or fluid-filled;
whether the testicle can be felt normally;
whether the swelling extends into the groin;
whether it changes when standing or lying down;
whether it enlarges with coughing or straining;
whether there is tenderness, redness or skin change.

Four traditional questions remain particularly useful:

Can the examiner get above the swelling?
If not, an inguinoscrotal hernia may be present.
Is the lump separate from the testicle?
A separate lump is commonly an epididymal cyst. A lump within the testicle requires urgent investigation.
Does the swelling transilluminate?
Fluid-filled swellings such as hydroceles and some cysts may allow light to pass through them.
Does it change with posture or straining?
A varicocele often becomes less prominent when lying flat.

Where testicular cancer is suspected, the abdomen, lymph nodes and breasts may also be examined.

Scrotal ultrasound

Ultrasound is the most useful investigation for most scrotal lumps.

It can distinguish:

intratesticular from extratesticular lumps;
solid from cystic lesions;
hydrocele from other swellings;
varicocele from other cord abnormalities;
inflammation from some other causes of pain;
normal from abnormal blood flow.

Colour Doppler ultrasound assesses blood flow within the testicle.

Ultrasound is highly accurate for detecting a testicular mass. However, it must be interpreted alongside the clinical history and examination, particularly when torsion is suspected.

Where facilities permit, I aim to arrange ultrasound at the same visit so that a man who arrives understandably worried can often leave with a clear diagnosis and plan.

Urine and infection tests

Where infection is suspected, investigations may include:

urine dipstick testing;
midstream urine culture;
first-void urine testing for chlamydia and gonorrhoea;
blood tests where there is fever or significant infection.

The tests chosen depend on symptoms, sexual history and previous urinary problems.

Testicular tumour markers

Where a testicular tumour is suspected, blood tests may include:

alpha-fetoprotein, or AFP;
beta-human chorionic gonadotrophin, or β-hCG;
lactate dehydrogenase, or LDH.

AFP may be raised in non-seminomatous germ-cell tumours but should not be elevated in pure seminoma.

β-hCG may be raised in either seminoma or non-seminomatous disease.

LDH is less specific but can reflect tumour burden.

Normal tumour markers do not exclude testicular cancer.

CT and MRI scanning

CT scanning of the chest, abdomen and pelvis may be used to stage a confirmed testicular malignancy.

MRI is not routinely required but can occasionally help clarify an equivocal ultrasound finding.

Semen analysis and hormone tests

Semen analysis may be appropriate when:

infertility is a concern;
a varicocele is present;
surgery involving the epididymis is being considered;
both testicles have been affected by infection or another condition.

Hormonal tests may be requested where there is concern about testosterone production or testicular function.

Why is a suspected testicular tumour not biopsied through the scrotum?

Routine biopsy through the scrotal skin is avoided when testicular cancer is suspected.

A scrotal biopsy can disrupt the normal lymphatic drainage and potentially contaminate a different tissue plane.

Diagnosis and initial treatment are usually achieved through an inguinal approach, using an incision in the groin rather than through the scrotum.

Treatment of scrotal lumps and pain

Treatment of testicular torsion

Testicular torsion is treated with emergency surgery.

The spermatic cord is untwisted, and the testicle is assessed for recovery of blood flow.

If it remains viable, it is fixed in position with sutures to prevent future twisting. The opposite testicle is usually fixed during the same operation because the anatomical predisposition is commonly present on both sides.

If the affected testicle is no longer viable, it may need to be removed. A testicular prosthesis can be discussed either at the time or later.

Treatment of testicular cancer

The initial treatment for a suspected testicular cancer is usually radical inguinal orchidectomy.

This involves removing the testicle and spermatic cord through an incision in the groin.

Before treatment, the consultation should include discussion of:

fertility;
sperm banking;
testosterone;
the option of a testicular prosthesis;
the likely further investigations;
the possibility of additional treatment.

Where practical, sperm may be stored before orchidectomy. However, clinically urgent surgery should not be delayed unnecessarily.

Further treatment depends on the tumour type and stage and may include:

surveillance;
chemotherapy;
radiotherapy;
retroperitoneal lymph-node surgery.

Treatment decisions are made through a specialist testicular cancer multidisciplinary team.

Treatment of epididymo-orchitis

Treatment may include:

appropriate antibiotics;
pain relief;
anti-inflammatory medication where suitable;
scrotal support;
rest;
sexual health assessment;
partner notification and treatment where relevant.

Symptoms may take time to resolve even after the infection has been treated. Persistent swelling or failure to improve should be reassessed.

Treatment of chronic scrotal pain

Chronic scrotal pain is best treated using a structured, stepwise approach.

1. Confirm the diagnosis

The first priority is to exclude:

cancer;
torsion;
infection;
hernia;
significant varicocele;
other structural pathology.

Understanding that no sinister condition has been found can itself reduce anxiety and pain amplification.

2. Conservative treatment

Initial measures may include:

supportive underwear;
activity modification;
avoiding specific triggers;
heat;
an appropriate trial of anti-inflammatory medication;
management of constipation or urinary symptoms where relevant.

3. Neuropathic pain medication

When nerve-related pain is suspected, medicines such as amitriptyline, gabapentin or pregabalin may be considered.

These medicines need to be used at an appropriate dose and for a sufficient period before their effect can be judged.

4. Pelvic floor physiotherapy

Some men with chronic testicular pain have overactivity or tenderness of the pelvic floor muscles.

Specialist pelvic floor physiotherapy can be particularly useful where scrotal pain is associated with:

perineal pain;
painful ejaculation;
urinary symptoms;
pelvic tension;
pain made worse by sitting.

5. Spermatic cord block

A spermatic cord block involves injecting local anaesthetic around the nerves of the spermatic cord.

It can be both:

diagnostic, by identifying pain carried through the cord nerves; and
therapeutic, by providing temporary relief.

A strong temporary response may help identify men most likely to benefit from microsurgical denervation.

6. Microsurgical denervation of the spermatic cord

Microsurgical denervation divides small pain-carrying nerve fibres while preserving important structures such as:

the testicular artery;
the vas deferens;
lymphatic vessels.

In carefully selected men who respond positively to a cord block, meaningful long-term improvement is achieved in a substantial majority.

7. Epididymectomy

Removal of the epididymis may be considered where pain is clearly and consistently localised to it, particularly in selected cases of post-vasectomy pain.

Because epididymectomy affects sperm transport, fertility implications must be discussed.

8. Orchidectomy

Removal of the testicle is reserved for exceptional cases after other options have failed.

It is not guaranteed to relieve pain, particularly where the pain has become centrally sensitised or neuropathic. Thorough counselling is therefore essential.

Fertility and hormonal considerations

Loss of one testicle does not usually prevent a man from fathering children or producing sufficient testosterone. A healthy remaining testicle can generally compensate.

However, fertility should be considered before treatment because:

some men with testicular cancer already have reduced sperm production;
chemotherapy and radiotherapy can affect fertility;
epididymal surgery can obstruct sperm transport;
severe bilateral infection can affect both testicles;
varicocele may be associated with impaired semen quality;
surgery involving both sides carries greater implications.

The discussion should reflect the individual man’s age, family plans, existing fertility and proposed treatment.

How to check your testicles

Men should be familiar with the normal size, shape and texture of their own testicles.

Checking after a warm bath or shower can make examination easier because the scrotal skin is relaxed.

A simple approach is to:

Support the scrotum in one hand.
Gently roll each testicle between the thumb and fingers.
Feel the entire surface for a new hard lump or irregularity.
Notice any change in size, weight or consistency.
Identify the epididymis as the softer ridge behind and above the testicle.

One testicle commonly hangs lower than the other, and mild asymmetry can be normal.

Do not repeatedly squeeze or examine the area to the point of causing discomfort. The purpose is to recognise a persistent change, not to achieve certainty about the diagnosis yourself.

Seek assessment for:

a new hard lump;
enlargement of one testicle;
a persistent change in texture;
heaviness that does not settle;
unexplained persistent discomfort;
any abnormality you cannot confidently identify.

Frequently asked questions

Is a lump in the scrotum always cancer?

No. Most scrotal lumps are benign. Epididymal cysts, hydroceles, varicoceles and skin cysts are much more common than testicular cancer.
However, a new lump should be examined because it can be difficult to tell whether it arises from within or beside the testicle without clinical examination and ultrasound.

How can I tell whether a lump is on the testicle?

A lump arising from within the testicle may feel continuous with its normally smooth surface.
An epididymal cyst often feels separate and sits above or behind the testicle.
It is not always possible to make this distinction yourself. If you are unsure, arrange an examination rather than continuing to monitor it without a diagnosis.

Does testicular cancer cause pain?

Testicular cancer is often painless, but it can cause aching, heaviness or discomfort.
Pain does not prove that a lump is benign, and the absence of pain does not make it harmless.

How quickly should a painless testicular lump be assessed?

A new hard lump or change within the testicle should be assessed promptly.
It is not usually an accident-and-emergency situation when it is painless, but it should not be left for weeks or months.

How quickly should sudden severe testicle pain be assessed?

Immediately.
Attend an emergency department because testicular torsion must be excluded. The chance of preserving the testicle is greatest within the first few hours.

Can testicular torsion happen more than once?

Yes. Intermittent torsion can cause repeated attacks of severe pain that resolve spontaneously.
These episodes require assessment because a future attack may not untwist by itself.

Are epididymal cysts dangerous?

A confirmed epididymal cyst is benign and does not become cancerous.
Treatment is usually unnecessary unless it becomes uncomfortable or excessively large.

Can epididymal-cyst surgery affect fertility?

It can. Surgery may cause scarring or obstruction within the epididymis on the operated side.
This is particularly important for younger men who have not completed their families.

Does a hydrocele need surgery?

Not necessarily.
A hydrocele usually requires treatment only if it is uncomfortable, enlarging, interfering with activity or causing significant cosmetic concern. The underlying testicle should first be assessed adequately, often with ultrasound.

Will a hydrocele return after aspiration?

Aspiration alone has a high recurrence rate because it removes the fluid but not the sac producing or containing it.
Surgery is generally the more definitive option in men fit for an operation.

Does a varicocele cause infertility?

Most men with a varicocele are fertile.
Treatment may be considered when there is a palpable varicocele, abnormal semen analysis and difficulty conceiving, or when the varicocele causes persistent pain.

Can a sexually transmitted infection cause testicle pain?

Yes. Chlamydia and gonorrhoea can cause epididymitis or epididymo-orchitis.
Testing, appropriate antibiotics and partner management may be required.

My ultrasound is normal, but the pain is real. What happens next?

A normal ultrasound is reassuring because it excludes many structural problems.
It does not mean the pain is imaginary. Chronic scrotal pain may arise from nerves, pelvic floor muscles, previous surgery, spinal problems or referred pain.
A structured chronic-pain assessment is appropriate.

Can I father children with one testicle?

Usually, yes.
A single healthy testicle generally produces enough sperm and testosterone. Fertility preservation may nevertheless be discussed before cancer treatment or surgery affecting the remaining testicle.

Can I have a prosthesis after removal of a testicle?

Yes. A testicular prosthesis can often be inserted during the original operation or at a later date.
The advantages, limitations and possible complications should be discussed before surgery.

When should you see a urologist?

Seek emergency assessment

Attend an emergency department for:

sudden, severe testicular pain;
testicular pain with nausea or vomiting;
major trauma with severe swelling;
a painful irreducible groin or scrotal swelling;
rapidly spreading infection or skin discolouration;
severe systemic illness associated with scrotal symptoms.

Arrange prompt specialist assessment

Seek prompt assessment for:

a new hard testicular lump;
a change in testicular size or consistency;
a progressively enlarging swelling;
persistent pain lasting more than a few days;
recurrent episodes of severe pain;
a new hydrocele where the testicle cannot be felt;
a new right-sided or non-decompressing varicocele;
symptoms affecting fertility or sexual function.

Arrange routine assessment

A routine appointment may be appropriate for a longstanding, stable, painless swelling that you would like properly examined, diagnosed and explained.

Private assessment of a testicular lump or scrotal pain

Finding a lump or developing unexplained testicular pain can be extremely worrying. In many cases, the uncertainty causes more anxiety than the eventual diagnosis.

A specialist assessment usually involves:

a detailed clinical history;
examination of the testicles, epididymides, spermatic cords and groins;
scrotal ultrasound where appropriate;
urine, infection or tumour-marker testing where indicated;
a clear explanation of the diagnosis;
discussion of observation, medication or surgery.

Where local facilities permit, scrotal ultrasound can often be coordinated with the consultation so that a diagnosis and management plan are available without an unnecessary delay.

Sudden severe pain should always be assessed in an emergency department rather than through a routine private appointment.

About Mr Neil Haldar

Mr Neil Haldar is a Consultant Urological Surgeon at Buckinghamshire Healthcare NHS Trust.

He specialises in robotic and laparoscopic uro-oncology and has extensive experience in general and paediatric urology, including the assessment and treatment of:

testicular and scrotal lumps;
hydroceles;
epididymal cysts;
varicoceles;
acute and chronic scrotal pain;
paediatric scrotal conditions;
testicular abnormalities and urological emergencies.

He has performed more than 1,000 nerve-sparing robot-assisted radical prostatectomies and more than 600 laparoscopic renal procedures

Private consultations are available at selected hospitals and clinics across Buckinghamshire, the Thames Valley, Windsor and North-West London.