What Parents Need to Know About Sudden Testicular Pain

Podcast Transcript

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time. In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Lynn Woo, MD:

Welcome back to Little Health, the Cleveland Clinic Children's Podcast, where we talk about common health concerns in kids in a way that's clear, practical, and reassuring for families. I'm Lynn Woo, one of the pediatric urologists at Cleveland Clinic Children's, and today we're going to discuss a topic that can be really concerning for both kids and parents. That's testicular pain in boys. What can this mean? What to watch out for and when it needs urgent attention. I'm joined by my good friend and colleague, Dr. Jessica Hannick. She's an assistant professor of urologic surgery and a Cleveland Clinic pediatric urologist. Thank you so much for being here. Without further delay, let's dive in.

Dr. Jessica Hannick, MD:

Thanks for having me. So this is actually a really important topic and one that definitely comes up a lot more often than people might expect.

Dr. Lynn Woo, MD:

Yeah, so let's start broadly. When a boy complains about testicular pain or pain in their private parts, what are we potentially dealing with?

Dr. Jessica Hannick, MD:

So testis pain can really run the gamut in terms of severity and seriousness. Most of the time it's pretty mild and can be intermittent with a stable normal exam so everything looks normal if you look at your child and it might just be attributed to something as simple as growing pains as a boy progresses through puberty. Other times, it can be due to musculoskeletal causes like a strain from a sports injury. When there's no clear trauma or sports injury, but there is progressive worsening of the pain from initially mild and then moderate discomfort and maybe even if there's associated redness of the scrotum, it can be due to an infectious bacterial or viral cause such as epididymitis or orchitis or even an, a torsion or twisting of a structure called the appendix testis or the appendix epididymis. In cases where there's severe pain, however, we tend to be pretty concerned about things like emergent surgical diagnoses such as testicular torsion or inguinal hernias with bowel compromise.

And in less, very less frequent cases, kidney stones can even present with referred pain to the testicle.

Dr. Lynn Woo, MD:

So you just mentioned a ton of things and a ton of terms and it sounds like there are many, many reasons a boy might have testicular pain. So there's just really a big range from things that could be simple and uncomfortable but not necessarily dangerous to things that might really need some prompt attention. So where does testicular torsion fit into that? I know you had mentioned that in that long list and what exactly do you mean by the term testicular torsion?

Dr. Jessica Hannick, MD:

Sure. So testicular torsion occurs when the spermatic cord, and that's the cord that attaches the testicle to the inside of the body, it contains the blood flow to the testicle and it becomes twisted. This results in ischemia or decreased blood flow to the testicle, which essentially results in severe pain, swelling, and often a change in the position of the testicle to a higher position within the scrotum and maybe kind of like a horizontal lie and that's due to twisting and shortening of that spermatic cord.

Dr. Lynn Woo, MD:

And you're mentioning twisting of structures and pain, but why is this considered a true medical emergency?

Dr. Jessica Hannick, MD:

Think of testicular torsion like the equivalent of a heart attack of the testicle. So as the blood supply to the testicles decreased, the testicular tissues don't get adequate blood flow and they can really begin to die. While each situation is definitely unique, if blood flow to the testicle is not recovered within less than six hours or six hours or less, the chances of that testicle being salvaged becomes less and less.

Dr. Lynn Woo, MD:

Is there something particular that triggers the torsion event or would put someone at higher risk? I mean, as a parent, I'd be wondering, well, how can I stop this or how can I prevent it? Or is there something that my kid's doing that's going to make him at a higher likelihood of having a torsion event? Is it related to being kicked or doing sports or wearing pants that are too tight?

Dr. Jessica Hannick, MD:

So there's actually really not any sort of activity that causes testicular torsion. I usually tell parents and patients it's just really bad luck. Most of the time I've seen it in patients who are just sitting around or even sleeping and sometimes playing video games, but I'm not going to blame it on the video games, of course. The sports you play, the clothing you wear does not cause torsion, nor does getting kicked. That would be a bigger concern for something different called a fracture or rupture of the testicle. In some cases, patients will have an anatomic variant called a bell clapper deformity, which results in abnormal attachment of the spermatic cord to the epididymis and testis, but there's really no way to assess for that on physical exam.

Dr. Lynn Woo, MD:

So I can't just get an ultrasound or some special test.

Dr. Jessica Hannick, MD:

Yeah, there's no way that we could screen everybody for that, otherwise we would. It's really just something that we're able to see when we're operating on the testicle.

Dr. Lynn Woo, MD:

But how about a typical age group? Like is there a particular age where you tend to see it more often?

Dr. Jessica Hannick, MD:

So we always say it can happen at any age, but the most common age cohort would be in boys who are starting to approach puberty, definitely in puberty and then early adulthood. There's also a subset of children, newborn babies who can have testicular torsion, but that's totally different situation and that usually occurs actually before birth around the time the baby is delivered.

Dr. Lynn Woo, MD:

All right. So for our listeners today who have sons or relatives that are boys, you know, what are some key warning signs that could signify testicular torsion?

Dr. Jessica Hannick, MD:

So the most common signs of testis torsion include sudden onset of severe pain in one testicle or one side of the scrotum. I've had some patients and parents worry that if they take an oral pain med when something like that happens at home, that might mask the pain of testicular torsion, but usually the pain is so severe that even doing something like that isn't really gonna provide any relief and so it doesn't mask the pain. So you can definitely try that just to roll out other things, but severe, severe pain like taking you to your knees is a big warning sign.

Dr. Lynn Woo, MD:

So I'm hearing pain is definitely a concern. Are there any other key symptoms or findings, you know, say on a exam or, you know, checking it?

Dr. Jessica Hannick, MD:

Yeah. The other thing we'll often see is that the affected testicle, so the side where the pain is often is firmer than normal, or at least compared to the other side. It might have a higher than normal position in the scrotum or look like it's lying horizontally like I said earlier, rather than its typical up, down orientation. It's often also swollen relative to the other side and frequently because the pain is so severe, patients will become nauseous and even vomit.

Dr. Lynn Woo, MD:

That's definitely surprising, that it's not always just involving pain in the actual scrotal area. Kids can throw up or feel very nauseated because of that amount of pain.

Dr. Jessica Hannick, MD:

Yeah. So depending on the patient's age and familiarity and comfort with discussing such a sensitive part of their body, sometimes they'll really, you know, the younger kids will just tell their parents, "Oh, you know, their belly hurts or their groin hurts and they're nauseous," which can sort of be scary because it can be like a red herring and throw parents and clinicians even off track. So it's really important to try to suss things out and get a really full history from, yeah, your child or family member and even do, a thorough exam.

Dr. Lynn Woo, MD:

And so we've talked about the signs and symptoms of testicular torsion, which is definitely an emergency, but how do you think the symptoms, the age group, the exam might compare to some of the other less dangerous or less urgent causes of testicular pain?

Dr. Jessica Hannick, MD:

Yeah. So in benign or infectious causes of testis pain, so not emergency situations like torsion, the pain is usually a lot more mild and then it might either be intermittent where there's periods of complete relief of pain or start mild and then progressively worsen over several days. And sometimes it will actually happen on both sides and that would be very atypical of testicular torsion.

Dr. Lynn Woo, MD:

So any of those things could be a sign of something not torsion related. So you mentioned pain that's more gradual in onset, like over a couple days period, or pain that's involving both sides or pain that's sort of there and maybe getting better, not just

Dr. Jessica Hannick, MD:

Waxing and waning. Yeah. That's a lot less likely to be torsion.

Dr. Lynn Woo, MD:

So let's say the son of one of our listeners suddenly starts complaining of severe testicular pain. What would you advise that they do?

Dr. Jessica Hannick, MD:

So in any setting of severe testis pain where there's no relief from an oral pain med at home within 30 minutes, especially if there's any of those signs or symptoms that we just discussed, that child should be brought to the nearest emergency room. I find many times parents will bring their child to an acute care clinic or an urgent care, but they don't have the image testing or the treatment services available to care for torsion. This is a situation that needs to be managed in the emergency room.

Dr. Lynn Woo, MD:

Got it. So I'm hearing you say if it's severe and sudden onset pain, it's not a call your doctor and wait for a call back or head to your neighborhood urgent care situation.

Dr. Jessica Hannick, MD:

Yeah, most definitely not. Often the patients themselves will actually be asking their parent, "Please bring me to the ER because the pain is so severe." And that's what they should do.

Dr. Lynn Woo, MD:

And let's emphasize this again. How quickly are we talking about acting on this or getting your child checked out?

Dr. Jessica Hannick, MD:

So like I mentioned earlier, this is a very time sensitive diagnosis. Ideally, we would like to have patients with testis torsion in the OR well, well, well before the six hour mark since their symptoms started and that's gonna give us the best chance possible of saving that testicle.

Dr. Lynn Woo, MD:

So again, you're saying if there's sudden significant testicular pain and a parent doesn't know why, then the safest move is to just get evaluated in the emergency room, right?

Dr. Jessica Hannick, MD:

I would definitely agree. Time is testicle.

Dr. Lynn Woo, MD:

All right, perfect. So once the patient's in the emergency department, what can a family expect to happen?

Dr. Jessica Hannick, MD:

Yeah, so typically patients are first seen by a triage nurse and the suspicion for torsion is high enough, then they'll be whisked away to be seen by a healthcare provider who'll get the story, do an exam. Then the patient might be asked to provide a urine sample if there's less of a concern for something serious and if there's just a thought it might be an infectious process. But when the concern for torsion is high enough, the urology team is called right away to evaluate the patient and the patient often will undergo an ultrasound to assess the blood flow of the testicle that they're concerned about.

While all of this is going on, of course, the ER team will aim to manage the patient's ongoing pain. At times, depending on the chronology of how things are flowing, the ER team or the urology team might even try to untwist the testicle in the emergency room because that can help regain blood flow to that testicle. That's often done while the patient's awake with an examination maneuver and of course some pain meds.

Dr. Lynn Woo, MD:

Got it. So let's say we confirm that the patient actually has a testicular torsion. What's the treatment?

Dr. Jessica Hannick, MD:

Patients with acute testicular torsion have bought themselves an emergent trip to the operating room.

Dr. Lynn Woo, MD:

All right. What does that surgery involve then in, in simple terms?

Dr. Jessica Hannick, MD:

The surgery aims to untwist that twisted spermatic cord and then if the testicle looks like it's starting to regain blood flow and it can be salvaged, both that testicle as well as the other testicle, so not the one that's twisted, not the one that's causing pain. They're both secured into the scrotum in several points in order to substantially reduce the chances of torsion ever happening again in the future.

Dr. Lynn Woo, MD:

So this surgery does involve an incision and some suturing. Is it done under general anesthesia? How long does it normally take?

Dr. Jessica Hannick, MD:

Yeah, it's definitely done under a general anesthesia and it usually takes about an hour to an hour and a half, give or take and that depends on, you know, getting IVs, getting patients asleep and then usually patients can go home the same day as their operation.

Dr. Lynn Woo, MD:

Now, let me go back to that point that you made about operating on both testicles. Why would you do that if the torsion's only affecting one side?

Dr. Jessica Hannick, MD:

Great question. Because patients with a history of torsion may have that anatomic variant we talked about, the bell clapper deformity, that may put them at a higher risk for torsion of the other testicles. So traditionally, most providers will operate on both sides to reduce that risk of torsion happening on either side in the future.

Dr. Lynn Woo, MD:

So this definitely can be a preventative move.

Dr. Jessica Hannick, MD:

Yeah, most definitely.

Dr. Lynn Woo, MD:

And do patients need to come into the hospital or be admitted after this surgery?

Dr. Jessica Hannick, MD:

No. As I mentioned earlier, usually patients will go home the same day or evening as their surgery. Of course, if it's a really, really late at night and, you know, people aren't comfortable driving home, they can spend some time, but usually it's a same day surgery. Most patients may need a week off of typical activities such as school, sports, gym, and all that until they're able to walk a little bit more normally without pain. And then often we'll recommend several weeks off sports gym and exercise for similar reasons and because their incisions are still healing so we don't want them to be at risk for worsening pain, bruising, or breakdown of that incision.

Dr. Lynn Woo, MD:

Do they typically have a lot of stitches?

Dr. Jessica Hannick, MD:

Everybody does it a little differently, but I'd say that their incision is about three to five centimeters and it can be multiple small incisions or just one running incision, but they're always dissolvable so they don't need to come back to the office to have those removed.

Dr. Lynn Woo, MD:

In general, what do you think the pain is like during the recovery period?

Dr. Jessica Hannick, MD:

I usually describe it as a really intense workout to children where they'll have some discomfort in their scrotum and they'll wanna wear some tighter fitting underwear and take Tylenol or ibuprofen and often ice that area, but it's not debilitating pain.

Dr. Lynn Woo, MD:

I'd imagine it feels better than when they initially came in.

Dr. Jessica Hannick, MD:

Most definitely.

Dr. Lynn Woo, MD:

Great. So it sounds like if we can diagnose and treat the torsion right away, the outcome can be pretty good.

Dr. Jessica Hannick, MD:

Yeah. In most cases where torsion is promptly treated, I would argue that there are no long-term negative consequences.

Dr. Lynn Woo, MD:

So a parent's gonna wanna know, can my son still have kids?

Dr. Jessica Hannick, MD:

Yeah.

Dr. Lynn Woo, MD:

Can he still make hormones normally if he's had a torsion event?

Dr. Jessica Hannick, MD:

Yeah. These patients can continue on with their lives to have normal hormonal and fertility function.

Dr. Lynn Woo, MD:

Now we did talk about that critical time window. What if there is a delay to getting to the emergency room or getting the surgical treatment?

Dr. Jessica Hannick, MD:

Well, when there are substantial delays in diagnosis and or treatment, this can mean that the blood supply to the testicles is being affected. So there can be atrophy of the testis and that means that, you know, the testicle becomes smaller, part of it essentially has died off. And in the worst case, if it looks like that there's no chance we're gonna regain that testicle, it would just pose a risk for infection or continued pain, we actually will remove it.

Dr. Lynn Woo, MD:

Wow. So the key here is that outcomes are really good if you recognize and treat this early, but timing obviously really matters.

Dr. Jessica Hannick, MD:

Absolutely.

Dr. Lynn Woo, MD:

This can obviously be an uncomfortable topic for kids to bring up and how do you recommend that parents approach this? Teenagers aren't always known for being, you know, great communicators and especially when it comes to something kind of private or embarrassing.

Dr. Jessica Hannick, MD:

Yeah. I would argue that as with all things that are critical to fostering a good relationship, communication is key. Having a supportive, open relationship with your child is essential to creating an environment where they feel they can safely share their concerns, even with sensitive topics like their genitals. And, you know, I wouldn't necessarily bring this up as a first time conversation, but setting the stage early and often about, "Hey, it's okay to talk to me about any of these things if you're worried," and reassuring them when they ask those questions is really important.

Dr. Lynn Woo, MD:

That's great. Now, if we have any kids or particularly teens that are listening to this podcast, do you have any specific advice for them or something that you'd want them to know?

Dr. Jessica Hannick, MD:

I would reassure teens that there's never any harm in speaking up to their parents or supportive guardian if they have any concerns about testicular pain. In the least serious situation, maybe everything is fine and they'll be reassured of that by a clinician, but in the worst case, they might have torsion and speaking up early means that they can get prompt and successful treatment so that they have no long-term health consequences.

Dr. Lynn Woo, MD:

That's so great.

Dr. Jessica Hannick, MD:

The other thing I'd recommend to teens since, you know, it's a sensitive area and they might just start to become familiar with their body around the age of puberty and before that is that it's really important for boys and young men to be familiar with their anatomy. So they should, you know, intentionally check that area and know what their normal is so that in the future if something like this happens, they will be able to notice the differences and be a little bit clearer potentially with their parents or guardian about the change

Dr. Lynn Woo, MD:

Yeah, that makes sense. So just like during normal bathing or

Dr. Jessica Hannick, MD:

Showers, stand up, make sure there's two, make sure they're down, know what, you know, normal texture and sensation of that area are and if they feel anything inside and, what the skin looks like, if there's swelling on one side or the other, just basic things like that.

Dr. Lynn Woo, MD:

Yeah, it definitely makes sense to know what they think is normal so that they can realize if there's something unusual happening and report that right away.

Dr. Jessica Hannick, MD:

Absolutely.

Dr. Lynn Woo, MD:

So the take home is testicular pain is something that should be always taken seriously. There's a wide variety of things that could be going on, but we absolutely need to make sure it's not something dangerous like torsion. So when in doubt, it's always appropriate to get this checked out right away.

Thank you again for joining us on Little Health. We hope you feel better prepared to take charge of your son's health and initiating those sometimes awkward conversations when they matter most. If you'd like to schedule an appointment with Dr. Hannick or another pediatric urologist at Cleveland Clinic Children's, please call 216.444.5600. That's 216.444.5600. Thank you and we'll see you next time.

Dr. Jessica Hannick, MD:

Bye-bye.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.