Scrotal Pain
Scrotal pain is an acute or chronic discomfort in the scrotum or its contents, commonly caused by conditions such as testicular torsion, epididymitis, or trauma, requiring urgent evaluation to rule out surgical emergencies.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Acute epididymitis / epididymo-orchitis | Gradual onset, fever, dysuria, +ve Prehn's sign, tender epididymis | 「小便有冇痛？抬高個波痛有冇好啲？」(Dysuria? Relief with elevation?) |
| Torsion of testicular appendage | Pre-pubertal, focal upper pole tenderness, blue dot sign [2] | 「痛嗰度係咪喺最頂嗰度？」(Is pain at the very top?) | |
| Serious Not To Miss | Testicular torsion | Sudden severe pain, N/V, high-riding testis, absent cremasteric reflex, -ve Prehn's sign [1][2][3] | 「痛係咪好突然嘅？有冇嘔？」+ high-riding testis on exam |
| Fournier's gangrene | DM, perineal pain, spreading erythema, crepitus, sepsis [4] | 「陰囊皮膚有冇變黑或者有氣泡感？」(Skin necrosis or crepitus?) | |
| Testicular tumour | Painless hard mass, non-transilluminant, inseparable from testis | 「有冇摸到硬嘢，唔痛嗰種？」(Painless hard lump?) | |
| Incarcerated / strangulated inguinal hernia | Cannot get above swelling, irreducible, bowel Sx | 「個腫有冇去到腹股溝？推唔推得返？」(Extends to groin? Reducible?) | |
| Pitfalls | Referred pain from renal colic | Flank pain, haematuria, colicky | 「腰有冇痛？小便有冇血？」(Flank pain? Haematuria?) |
| HSP scrotal involvement (paeds) | Purpura, arthralgia, abdominal pain [5] | 「腳有冇紅疹？肚有冇痛？」(Leg rash? Abdominal pain?) | |
| Masquerades | Drug-related (e.g. amiodarone epididymitis) | Medication Hx | 「你食緊咩藥？」(What medications?) |
| Trying to Tell Me Something? | STI anxiety / relationship concern | Young male afraid of STI disclosure to partner | 「你有冇擔心性病或者影響伴侶？」(Worried about STI or partner?) |
| Fear of cancer / infertility | Health anxiety driving the visit | 「你係咪擔心會唔會係癌症或者影響生育？」(Worried about cancer/fertility?) |
GC 193 HIGH YIELD: Scrotal painful lumps = torsion of testis, torsion of appendage, epididymo-orchitis, strangulated inguinal hernia, haematocele/haematoma. Painless lumps = inguinal hernia, hydrocele, epididymal cyst, spermatocele, varicocele, testicular tumour, skin swelling. [1]
GC 013 HIGH YIELD: Acute scrotal pain — imaging modality of choice is Doppler USG to rule out torsion. DDx: testicular torsion, torsion of appendix testis, acute epididymitis/epididymo-orchitis, incarcerated inguinal hernia, testicular trauma. [6]
Past paper HIGH YIELD (2022 Q27): Poorly-controlled DM + perineal/scrotal pain + erythema + crepitus = Fournier's gangrene [4]
Scrotal Pain — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, rapport | 「你好，我係X醫生，今日由我同你傾吓。你點稱呼呀？」(Hello, I'm Dr X. How should I address you?) | Warm opening scores interpersonal marks |
| 0:30–1:00 | Open-ended chief complaint | 「你今日嚟有咩唔舒服呀？可以同我講多啲。」(What brought you in today? Tell me more.) | Lets patient tell their story; avoids premature closure |
| 1:00–3:00 | HPI — symptom analysis + red flags | 「痛咗幾耐？突然定慢慢嚟？有冇嘔？個波有冇升高咗？抬高個波痛有冇好啲？」(How long? Sudden or gradual? Vomiting? Is testis riding high? Relief with elevation?) | Discriminates torsion vs epididymitis — the critical split. Cover SOCRATES, nausea/vomiting, urinary Sx, discharge, trauma, sexual Hx |
| 3:00–3:30 | PMHx / DHx / Allergy / FHx | 「你之前有冇咩病或者做過手術？食緊咩藥？有冇藥物敏感？屋企人有冇類似問題？」 | Completeness marks; relevant to DDx |
| 3:30–4:00 | Social Hx, Sexual Hx | 「我問少少私人嘢，你介唔介意呀？你有冇性伴侶？有冇用安全套？」(Do you mind a personal question? Do you have a partner? Condom use?) | Permission → scores empathy. Sexual Hx key for epididymitis (STI). Must ask occupation + smoking/alcohol |
| 4:00–4:45 | ICE — Ideas, Concerns, Expectations | 「你自己覺得會唔會係咩嚟嘅？最擔心啲咩？你嚟到想我幫你做啲咩？」(What do you think it might be? What worries you most? What were you hoping I could do today?) | Hidden agenda: patient may fear cancer/infertility/STI. This is where the RFC often hides. |
| 4:45–5:30 | Signpost → summarise → physical exam plan | 「等我總結吓：你…（summarise）。我想幫你檢查吓，可以嗎？」 | Shows structure; scores signposting & summarising marks |
| 5:30–6:00 | Close: explain plan, safety-net, empathy | 「我覺得最重要嘅係排除下扭轉/感染，我會幫你安排檢查。如果痛突然加劇或者嘔，一定要即刻返急症室。你有冇嘢想問？」 | Safety-net is essential for scrotal pain; checks understanding; empathic close |
Uncovering the hidden agenda: Ask 「點解今日嚟呀？」 and 「最擔心啲咩？」 — patient may fear testicular cancer, infertility from torsion, or an STI they haven't disclosed. The RFC is often "fear of cancer" or "worried about fertility" rather than just "pain."
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset | When did pain start? Sudden or gradual? | 「幾時開始痛？突然定慢慢嚟？」 | Sudden onset → torsion; gradual → epididymitis [1][2] | Torsion (sudden); epididymitis (gradual) |
| Character | Constant or intermittent? How severe? | 「痛係持續定一陣陣？幾痛（1-10）？」 | Severe constant → torsion; dull ache → varicocele | Torsion; varicocele |
| Radiation | Does pain go to groin/lower abdomen? | 「痛有冇去到腹股溝或者肚？」 | Radiation to groin/abdomen common in torsion | Torsion, renal colic (referred) |
| N/V | Any nausea or vomiting? | 「有冇作嘔或者嘔？」 | N/V in 90% of torsion [3] | Torsion |
| Swelling | Any scrotal swelling? | 「個陰囊有冇腫？」 | Swelling present in torsion, epididymitis, hydrocele | Multiple DDx |
| Fever | Any fever? | 「有冇發燒？」 | Fever → infection (epididymitis/orchitis); absent/mild in torsion [1] | Epididymitis, Fournier's gangrene |
| Urinary Sx | Dysuria, frequency, discharge? | 「小便有冇痛、密咗、或者有分泌物？」 | Urinary Sx → UTI / epididymitis | Epididymitis (STI or UTI-related) |
| Discharge | Any urethral discharge? | 「尿道口有冇嘢流出嚟？」 | Purulent → GC; clear → Chlamydia | STI-related epididymitis |
| Sexual Hx | Sexually active? New partners? Condoms? | 「你有冇性生活？有冇新嘅伴侶？有冇用安全套？」 | <35y epididymitis usually STI-related (Chlamydia/GC) | STI epididymitis |
| Trauma | Any injury to scrotum? | 「有冇撞親或者受過傷？」 | Trauma → haematocele, testicular rupture | Haematocele |
| Activity | Heavy lifting / sport before onset? | 「痛之前有冇做運動或者搬重嘢？」 | Abdominal straining triggers torsion via cremaster | Torsion |
| Testis position | Does testis feel higher than usual? | 「你覺得個波有冇升高咗？」 | High-riding testis = torsion [1][2] | Torsion |
| Previous episodes | Similar pain before? Intermittent torsion? | 「之前有冇試過類似嘅痛？」 | Intermittent torsion can recur | Intermittent torsion |
| Cryptorchidism | Were your testes always in the scrotum? | 「細個嗰陣個波有冇喺陰囊入面？」 | UDT = ↑risk of torsion [2] | Torsion |
| PMHx | DM? Immunosuppression? | 「你有冇糖尿病或者長期病？」 | Poorly-controlled DM → Fournier's gangrene [4] | Fournier's gangrene |
| Red flags — skin | Any skin necrosis / crepitus / spreading redness? | 「陰囊皮膚有冇變黑/爛/越嚟越紅？」 | Fournier's gangrene → life-threatening [4] | Fournier's gangrene |
| Lump features | Painless lump noticed? How long? | 「有冇摸到硬嘢？幾耐？」 | Painless firm testicular mass → tumour until proven otherwise [1] | Testicular cancer |
| ICE | What do you think / worry / expect? | 「你自己覺得係咩？最擔心咩？想我幫你做咩？」 | Marks for ICE; uncovers hidden agenda | Fear of cancer, STI, infertility |
| Functional | How does this affect work/daily life? | 「呢個問題對你返工/生活有冇影響？」 | Scores biopsychosocial marks | Social problem for CRF |
Case Report Form Answer Builder
Format: "[Age] [sex] presents with [duration] of [laterality] scrotal/testicular pain."
Must include:
- SOCRATES of scrotal pain (onset, character, radiation, severity, duration)
- Associated Sx: N/V, swelling, fever, urinary Sx, discharge
- Relevant negatives: no trauma, no previous episodes (or positive if present)
- Sexual Hx if relevant (STI risk)
- Pertinent PMHx (DM, UDT)
Likely RFC examples:
- "Worried the pain could be testicular torsion/cancer"
- "Concerned about fertility"
- "Embarrassed about possible STI; wants confidential testing"
- "Pain affecting work/sport performance"
How to phrase: Pick the patient's OWN stated concern, not just the symptom. E.g., "Patient consulted because of concern about possible cancer causing the scrotal pain."
| Component | Likely Content | Exact Wording for CRF |
|---|---|---|
| Ideas | "Patient thinks it might be an infection / pulled muscle / cancer" | "Patient thinks pain may be due to infection from recent sexual contact" |
| Concerns | "Worried about cancer / infertility / STI" | "Patient is worried this could be testicular cancer and affect his fertility" |
| Expectations | "Wants scan / referral / antibiotics / reassurance" | "Patient expects an ultrasound to rule out serious causes" |
In a young adult male with acute/subacute scrotal pain in FM setting:
- If gradual onset + fever/dysuria + tender epididymis + +ve Prehn's sign → Acute epididymitis (most common in adults >18y in primary care)
- If sudden onset + N/V + high-riding testis + absent cremasteric reflex → Testicular torsion (surgical emergency — refer immediately)
- If pre-pubertal + focal upper pole tenderness + blue dot sign → Torsion of testicular appendage
Minimum supporting evidence to write: State the onset pattern, key positive and negative signs, and one discriminating feature.
| DDx | One Key Discriminator |
|---|---|
| 1. Testicular torsion | Sudden onset, high-riding testis, absent cremasteric reflex, -ve Prehn's sign |
| 2. Acute epididymitis / epididymo-orchitis | Gradual onset, fever, dysuria/discharge, +ve Prehn's sign, tender epididymis |
| 3. Torsion of testicular appendage | Pre-pubertal, focal upper pole tenderness, blue dot sign, less severe pain, no N/V |
(If the patient is older/diabetic, substitute Fournier's gangrene. If painless mass, substitute testicular tumour.)
| Domain | Problem |
|---|---|
| Biological | Acute scrotal pain requiring urgent assessment ± Doppler USG to exclude torsion |
| Psychological | Anxiety about possible cancer / infertility / STI; embarrassment about genital examination |
| Social | Impact on work/sport/school; relationship stress if STI is suspected; need to disclose to partner |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Testicular torsion | High-riding testis with horizontal lie + absent cremasteric reflex [1][2][3] | Inspect: testis sits higher than contralateral side; lies horizontally. Stroke inner thigh → no cremasteric retraction | Torsion shortens the cord → testis rides up; twisted cord abolishes normal reflex |
| Acute epididymitis | +ve Prehn's sign (pain relieved by elevating testis) [2] | Gently elevate affected testis → ask if pain improves | Elevation relieves venous congestion of inflamed epididymis; does NOT relieve ischaemic pain of torsion |
| Torsion of testicular appendage | Blue dot sign [2] | Inspect upper pole of testis through scrotal skin → small blue-black spot visible | Infarcted appendix testis visible through thin scrotal skin |
| Fournier's gangrene | Palpable crepitus over erythematous scrotum [4] | Palpate scrotal skin → feel for subcutaneous gas (crepitus) + spreading erythema | Gas-producing organisms cause subcutaneous emphysema — pathognomonic |
| Testicular tumour | Firm/hard painless mass inseparable from testis, does not transilluminate [1] | Palpate testis → feel for hard, non-tender mass; transillumination test → opaque | Solid tumour tissue does not transmit light; inseparable from testis body |
| Inguinal hernia (strangulated) | Cannot get above swelling + tenderness + irreducible [1] | Try to palpate above the scrotal mass → fingers cannot pass above it into inguinal canal | Inguinoscrotal hernia extends from inguinal canal into scrotum; strangulation = tender and irreducible |
Top Traps That Lose Marks
- Forgetting to ask about N/V — present in 90% of torsion; its absence makes torsion less likely.
- Not asking sexual history — you will miss STI-related epididymitis. Always ask with permission phrase first.
- Mixing up Prehn's sign — +ve Prehn's (pain RELIEVED by elevation) = epididymitis; -ve Prehn's = torsion. Don't get it backwards.
- Failing to identify the RFC as something beyond the symptom — the patient may fear cancer or infertility, not just pain.
- Stating "testicular torsion" as most likely in an adult with gradual onset, fever and dysuria — epididymitis is far more common in adults in primary care. Match your diagnosis to the clinical features.
- Forgetting to safety-net — if torsion is possible, the patient MUST go to A&E immediately. Always say this.
"Must Not Miss" Red Flags → Urgent Referral:
- Sudden severe pain + N/V + high-riding testis → Torsion: refer to A&E for emergency scrotal exploration. Irreversible ischaemic damage after 6–12 hours [2][3]
- Spreading scrotal erythema + crepitus + sepsis in diabetic patient → Fournier's gangrene: emergency surgical debridement [4]
- Painless hard testicular mass → Testicular tumour: urgent urology referral + USG + tumour markers (AFP, β-hCG, LDH)
Shortest Safe Safety-Net Line: 「如果痛突然加劇、嘔、或者個波升高咗，一定即刻去急症室，唔好等。」 (If pain suddenly worsens, you vomit, or testis rides up — go to A&E immediately, don't wait.)
High Yield Summary
What to ASK: Onset (sudden vs gradual), N/V, fever, urinary Sx, discharge, sexual Hx (with permission), trauma, previous episodes, DM, and ICE — especially fear of cancer/infertility/STI.
What to WRITE on CRF:
- CC/HPI: Age + sex + duration + laterality + onset pattern + key associated Sx + relevant negatives
- RFC: The patient's REAL worry (cancer? fertility? STI?), not just "scrotal pain"
- ICE: Use the patient's own words
- Most likely Dx: Match to stem — gradual + fever + dysuria = epididymitis; sudden + N/V = torsion
- DDx: Always include torsion (even if not #1), epididymitis, and torsion of appendage
- Biopsychosocial: Biological (urgent assessment needed), Psychological (anxiety/embarrassment), Social (work/relationship impact)
- Physical sign: High-riding testis + absent cremasteric reflex (torsion) OR +ve Prehn's sign (epididymitis)
What NOT TO MISS: Testicular torsion is a time-critical emergency — always exclude it first. Fournier's gangrene kills. Painless hard mass = cancer until proven otherwise.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 193. Inguinal and scrotal swelling different types of hernia.pdf (p.7) [2] Senior notes: Maksim Surgery Notes.pdf (p.327-328 — common scrotal conditions table) [3] Senior notes: Adrian Lui Pediatrics Notes.pdf (p.348-349 — testicular torsion) [4] Past papers: 2022 Fourth Summative MCQ.pdf (Q27 — Fournier's gangrene) [5] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p.703 — HSP scrotal involvement) [6] Lecture slides: GC 013. Emergency radiology.pdf (p.54 — acute scrotal pain imaging)
RUQ Pain
Right upper quadrant pain is abdominal pain localized beneath the right costal margin, most commonly associated with hepatobiliary or gallbladder pathology such as cholecystitis or cholelithiasis.
Shortness Of Breath / Dyspnoea
Dyspnoea is the subjective sensation of difficult, labored, or uncomfortable breathing arising from interactions among physiological, psychological, and environmental factors.