Executive summary
- Scrotal pain is torsion until confidently proven otherwise. The key first job is to separate likely epididymo-orchitis from testicular torsion and other urgent causes.
- Epididymo-orchitis usually causes unilateral pain, tenderness, and swelling developing over hours to days, often with urinary or sexual-history clues.
- Management depends on likely cause: suspected STI pathways differ from likely enteric-organism disease in older men or those with urinary instrumentation risk.
Assessment priorities
- Take a focused history: onset speed, sexual history, dysuria, urethral discharge, urinary symptoms, systemic features, trauma, and previous episodes.
- Do not miss torsion: sudden severe pain, vomiting, a high-riding or horizontally lying testis, or marked diagnostic uncertainty should trigger same-day surgical/urological assessment.
- Examination matters: document testicular position, swelling, focal tenderness, skin changes, fever, and the presence or absence of urethral discharge.
Treatment approach
- If STI is the most likely cause, NICE CKS advises urgent referral to a sexual health service for testing, treatment, and partner/contact management.
- If enteric organisms are more likely and admission is not needed, CKS includes oral ofloxacin 200 mg twice daily for 14 days or oral levofloxacin 500 mg once daily for 10 days as options.
- Supportive care: rest, scrotal support, and analgesia are useful, but they do not replace reassessment if symptoms are severe or worsening.
- Arrange follow-up to check clinical response and culture results where relevant.
Frequently asked questions
What is the biggest diagnostic error?
Missing testicular torsion by assuming that all tender swollen testes are epididymo-orchitis. If torsion is plausible, same-day surgical assessment is the safer route.
When should I think STI rather than enteric organism?
Age, sexual history, urethral symptoms, and partner/contact risk can all point towards STI-related epididymo-orchitis, and NICE CKS advises urgent sexual-health referral in that setting.
Can this be managed with analgesia alone while waiting?
No. Supportive measures help, but suspected infection still needs an active treatment plan and suspected torsion needs immediate escalation.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.