What are the key differential diagnoses to consider in a patient presenting with chronic testicular pain?

When assessing a patient presenting with chronic testicular pain, key differential diagnoses to consider include epididymitis, orchitis, varicocele, hydrocele, inguinal hernia, testicular torsion (particularly intermittent), post-vasectomy pain syndrome, referred pain from the lower back or abdomen, and neoplastic causes such as testicular cancer. Chronic orchialgia may also be due to nerve entrapment or idiopathic causes after excluding other pathologies. It is essential to consider malignancy in the differential, especially if there is a palpable mass or other suspicious features, warranting urgent referral ¹.

Evaluation should include a thorough history and physical examination, scrotal ultrasound with Doppler to assess vascularity and exclude masses, and urine analysis to rule out infection. Persistent pain without identifiable cause after these investigations may suggest neuropathic pain or post-surgical syndromes (e.g., post-vasectomy) (Sigalos and Pastuszak, 2017). The integration of UK guidelines and recent literature emphasizes a systematic approach to exclude serious pathology while recognizing that chronic testicular pain often has multifactorial or idiopathic origins ¹ (Sigalos and Pastuszak, 2017).