Every man on the planet has at least one thing in common: that well known flinch when someone or something threatens to hit him in the testicles. The family jewels are ultrasensitive and even a quick tipper can bring a guy to his knees. Sometimes, balls can start hurting for no apparent reason. This pain can be intense and last for long periods of time. This article explores the causes of testicular pain, the treatment options and tips for when and how to discuss the matter with your doctor.
The main cause of testicular pain is injury. The acute pain is incredibly intense and can be associated with nausea, vomiting and referred pain in the lower back or abdomen. Generally, pain dissipates very shortly after injury. In some cases, it may last a few days, weeks or months depending on the severity of the injury. In rare cases, pain may continue indefinitely and interrupt normal life. This chronic testicular pain can be treated by a physician but may take several visits and treatment attempts before finding an approach that works.Testicular torsion is a rare type of injury that requires immediate medical attention. It happens when the testicle gets twisted and blood supply gets cut off. The common sign of torsion is a high-riding testis that is unresponsive (it doesn’t raise or lower like it usually does). Pain is sudden and severe and can be accompanied by nausea and vomiting. An ultrasound will show no blood flow to the testicle. Torsion is treated with emergency surgery that should ideally be performed within 4 hours to preserve full testicle function.
Why does getting hit in the balls hurt so much?
A shot to the groin hurts so much because testicles hang outside of the body unprotected by the bones, large muscles or fat layers that keep other organs safe. So, why are they out there? Sperm are fine-tuned little machines that need a precise environment for proper development. The optimal temperature for spermatogenesis, the processes of creating sperm, is 94 degrees Fahrenheit, which is approximately 4 degrees cooler than body temperature. To support this, Mother Nature placed the testicles on the outside of the body and equipped them with a mechanism for precise environmental control. The cremaster muscle responds to the external environment and keeps the testes an appropriate distance from the body to optimize temperature. So in a hot shower, the balls will hang low. In a cold lake, they draw up close and snug. The cremaster is also responsive to danger and will draw the testes in close in situations when it feels that injury is possible. Balls are pretty damn smart.
So, why do I get a weird feeling in my stomach when I get hit in the balls?
Similar to brain-freeze when eating ice cream or shoulder pain during a heart attack, stomach and abdomen sensations in response to testicular pain are a form of referred pain. The exact mechanism of referred pain isn’t very well understood, but generally nerves are organized in bundles, call plexuses, which connect to the spinal cord and fan out throughout the body. Referred pain occurs in regions that are connected to each other. The spermatic plexus, which connects the testes to the spine, are also connected to nerves in the kidneys, intestines and bladder, which in turn are connected to nerves in the stomach. Injury to the testicle can cause nausea, abdomen pain and even pain in the lower back. Interestingly, referred pain can work the other way too. Problems with the kidneys, intestine or even lower back can cause pain in the testicles.
What causes blue balls?
Sexual arousal causes physiological changes in the body. In men, the blood vessels in the penis and scrotum widen to increase blood flow, known as vasocongestion. Blood fills the penis and increased pressure causes an erection. Blood also flows into the testicle causing it to swell 25-50% of its original size. Upon ejaculation, blood is released and pressure goes down. If ejaculation does not occur, blood stays trapped in the testicle. The trapped blood not only causes pain, but it also slowly loses oxygen and causes the scrotum to take on a bluish color – hence the name “blue balls”.There are a few options for relieving blue balls. The simplest is ejaculation. If circumstances don’t allow for that, there are other ways to get the blood flowing. For instance, taking a cold shower or a run will stimulate the blood to flow away from the genitals and into other areas of the body.
Chronic testicular pain
While most testicular pain is temporary, it can persist days, weeks, months and even years. Doctors classify testicular pain as chronic if it last 3 months or longer. It may be episodic, occurring during activities such as sex, heavy lifting, long rides in the car, long periods of standing, or a persistent deep ache “like the day after you got hit there”. Other times it can be present like that feeling of the testicle getting pinched in the crotch of your underwear but re-adjustment doesn’t help. There are a lot of reasons for chronic testicular pain and getting to the root cause may require persistence and patience.Persistent pain can be inflammatory, infectious, or in most cases, idiopathic. Initial cases can be managed by your primary care physician. Complicated cases are referred to urologists who specialize in treating conditions of the urinary tract and male reproductive organs. In some cases, care may also require specialists in pain management.
Causes of Chronic Testicular Pain
There are a variety of causes for chronic testicular pain ranging from inflammation of the testicle due to an infection to kidney stones and urinary tract infections. A thorough examination and medical history will help diagnose what’s wrong and identify effective treatment options. This section of the article outlines the most common causes of testicular pain, how they are acquired and what is typically done to treat them.
Inflammation of the Reproductive Tract
Inflammation is a common cause of pain throughout the body. Inflammation occurs when the immune system suspects infection or injury and sends white blood cells out of the blood stream and into the tissue of the body to destroy foreign objects. Inflammation is identified by pain, swelling, and heat. Groin pain is often caused by inflammation of the reproductive tract often caused by infection or injury
Orchitis: Inflammation of the testicle. Most commonly caused by bacterial infection, sexually transmitted disease or the mumps.
Epididymitis: Inflammation of the epididymis (the tube that stores sperm while it matures). Most common cause of scrotal pain in adult men. May stem from infection but can also happen due to blockage or other issues.
Prostatitis: Inflammation of the prostate. Common cause of groin pain. 90% of the time there is no infection causing inflammation, the prostate just has issues.
Infections affecting the Testicle
Infections in and around the testicle are a leading cause of chronic testicular pain. Infections are caused by viruses or bacteria that cause an immune response often accompanied by pain (like a sore throat). Most infections that impact the reproductive system can be treated with antibiotics and anti-inflammatory drugs by primary care physicians. Here is a list of the most common infections that can lead to testicular pain:
Chlamydia & Gonorrhea: bacterial infections that are sexually transmitted. Most men do not have symptoms but some develop penile discharge, pain during urination, and swelling or pain in the testicle.
Mumps: A viral infection that often has very mild symptoms similar to a cold or flu. About 25% of men who contract mumps after puberty will experience some swelling / inflammation of the testis.
Tuberculosis: Tuberculosis (TB) is a bacterium that usually attacks the lungs, but it can also attack other parts of the body including the testicle. TB causes inflammation of the epididymis and/or testicle in 30-50% of cases.
Filariasis: This disease is transmitted by mosquitoes and impacts approximately 100 million people in tropical countries. Typical symptoms include hydroceles, swelling, and inflammation of the scrotum and penis. Western doctors may not be as familiar with the condition so it is important to mention recent travel if you have been in the tropics.
Post-Surgical Groin Pain
Most surgeries of the groin are minor with few complications. Occasionally, however, patients can experience post-surgical pain in the testicle.
Post-Vasectomy Pain Post-vasectomy pain affects up to 33% of vasectomized men. Most pain is minor and resolves on its own. Some men develop chronic pain (2-5%) known as post-vasectomy pain syndrome and can occur days, weeks, months and even years following their vasectomy. Pain can take various forms depending on the root cause. It can be constant or episodic occurring only during sex, ejaculation or physical exertion. Mechanisms of pain include:
Congested epididymis: Sometimes sperm get backed up with nowhere to go and this can cause pressure and discomfort. This is similar to the physiology of blue balls. Congested epididymis often causes more constant pain and can be relieved through a vasectomy reversal or other surgical interventions.
Sperm granulomas: Sperm can leak out of the epididymis and form lumps known as sperm granulomas that can be from 1 mm – 1 cm or more in size. Depending on size and position, sperm granulomas can cause varying levels of pain.
Scarring & cysts: As with other surgeries, vasectomies can cause scarring which produces hard tissues and cysts that can trap nerves and cause irritation and pain. This pain may become more pronounced during sexual activity as things are moving around.
Hernia Repair Surgery A minority of patients who undergo hernia repair surgery experience post-surgical testicular pain. Most commonly, it is caused by the nerve getting trapped in tissue, which irritates it and causes it to become over-sensitive. Nerve blocks are often a recommended treatment option in this case. In some cases, a doctor may recommend a removal of the mesh used to repair the hernia.
Abnormalities of the Testis: Lumps, Bumps & a Bag of Worms
Lumps, bumps and other structural abnormalities in the testicle are often painless. While most bumps are harmless, they should always be evaluated by a doctor to ensure they are not cancerous. Testicular cancer is the leading form of cancer in men 15-35 years old. Treatment of testicular masses will depend primarily on if they are cancerous, then on how much pain they cause and if they are interfering with fertility. Below is a list of types of lumps that are commonly found in the testicle.
Varicocele: Found in about 15% of all men, varicoceles are the most common structural abnormality of the testicle. A cousin to varicose veins, varicoceles are enlarged veins in the testicle that can cause them to feel heavy or cause aching after long periods of standing. Often a varicocele can’t be seen or felt, but in some cases they can cause the scrotum to feel like a “bag of worms.” Varicoceles can impact fertility and can be repaired surgically.
Testicular Cancer: While it is the most common form of cancer found in young men from 15-35 years of age, testicular cancer is incredibly rare, affecting 0.004% of all men and only 1% of masses found in the testicle are cancerous. However, early treatment has virtually 100% survival rate, so it is important to have any bump checked by a physician.
Sperm Granuloma: Sperm can leak out of the epididymis and form a hard ball that can cause pain or discomfort. The majority of sperm granulomas occur in vasectomized men.
Spermatocele: Imagine a river where things float along smoothly until they encounter an obstacle jutting out which can trap debris. Small pockets in the epididymis can trap sperm as they flow from the testicle to the vas deferens. As the sperm collect, they can create pressure and enlarge the pocket which in turn collects more sperm. With time, this can feel like a cyst on the epididymis. They do not cause any harm and are mostly left alone unless they are causing pain that interferes with every day activities.
Hydrocele: A hydrocele is a pool of liquid between the testicle and the scrotal wall and causes swelling of the testicle. They are often painless but can cause the testicle to feel heavy. In adults, hydroceles can be caused by injury, surgery or infection. Hydroceles are also the primary symptom in the mosquito-borne tropical disease, filariasis.
Referred Pain from the Abdomen
Injury in the testicle can cause sensations in the stomach and lower back known as referred pain. Referred pain can happen in the opposite direction when problems with kidneys, intestines and bladder can lead to pain in the testicle. The exact mechanism of referred pain isn’t very well understood, but generally nerves are organized in bundles, call plexuses, which connect to the spinal cord and fan out throughout the body. The spermatic plexus which connects the testes to the spine also connects to nerves in the kidneys, intestines and bladder. Most common causes of referred pain are:
Kidney stones: Kidney stones are tiny solid masses created by the kidneys out of minerals in urine. They are notoriously painful. Sometimes pain from stones will radiate down into the testicle.
Inguinal hernia: Inguinal hernias occur when tissue in the abdomen, usually part of the intestine, passes through inguinal canal, the route taken by the testicles when they descend. They are caused by congenital defect, weak abdominal muscles or increased pressure in the abdomen from frequent coughing or obesity. Symptoms include pain, especially when a person coughs, bends, or lifts a heavy object. In some people, they appear as a visible bulge just below the belt.
Urinary tract infections: Urinary tract infections (UTIs) are rare in men but do happen. Infection can occur anywhere along the urinary tract, including the urethra (the tube in the penis that urine comes out of), the bladder and the kidneys. Risk is elevated in men who have difficulty with incontinence, prostate problems, are not circumcised, or through sex with a partner who has a UTI. Most common symptoms include painful or more frequent urination, pressure in the abdomen, bad smelling urine and occasionally testicular pain.
Stress, Psychological & Idiopathic Causes of Testicular Pain
25% of men with chronic testicular pain have no identifiable cause. In these cases the pain is labeled as idiopathic, the medical term for “who the hell knows”. Idiopathic orchialgia is damn frustrating for both the patient and the physician because it creates a lot of guesswork around the effectiveness of various treatment options. In some cases, idiopathic orchialgia may be caused by stress, depression or anxiety. Literature states that there is a correlation between incidence of testicular pain and these psychological states. These emotional states commonly cause physical symptoms including pain, digestive problems, sleep issues, change in appetite, muscle tension, and pounding of the heart, which stem from an altered physiological state. Stress, anxiety and depression are all natural reactions to life circumstances but are often buried as we try to bottle up our emotions. This is particularly true in men and the body often will push back presenting physical symptoms when emotions are suppressed. It’s rough enough that life is hard, but it’s just wrong when it kicks you in the balls too. There are a lot of tricks for combating pain when it stems from psychological origins.
Body vs brain: One tool in the tool box is to force the body to alter the hormones available. Emotions are regulated by hormones and neurotransmitters in the brain such as oxytocin, ACTH, dopamine and serotonin. Different activities such as sex, exercise and sleep will alter these hormone levels in the body and in turn alter the biochemistry of the brain. Sometimes forcing the body to perform activities that stimulate the production of various hormones can create a positive feedback loop and reduce depression, stress or anxiety.
Finding new perspective: While it is difficult to do, altering perspective and finding reasons for gratitude, thinking about new possibilities or taking life one day at a time can alter the neural pathways that are firing and reduce physical symptoms that have psychological roots.
Breaking routine: A dramatic break in routine – a trip somewhere new, learning a new skill, changing habits or meeting new people can wake the brain up, stimulate the learning centers and can help to kick start positive feedback cycles that can improve optimism and outlook.
Working it through: Sometimes, particularly in situations involving grief or extreme hardship, it just takes time to work it through. Communicating with your spouse or close friends and family, writing or finding support community either on-line or in-person can help identify feelings and work through them. Depression in men is highly stigmatized and is much more common than it appears. A support system is vital to helping a man get back on his feet. In circumstances where testicular pain does not have an obvious cause, it is important to talk with your physician about what else is going on in your life to consider if they are contributing to testicular pain.
How Psychologists can help with Chronic Pain
According to the American Psychological Association, in some cases psychologists can be as effective as surgery at reducing or eliminating pain.They have specific techniques that enable the brain to re-wire how it processes and deals with pain signals. Mind-body techniques for dealing with chronic pain may feel like a band-aid on a bullet wound, but many are firmly rooted in science and are commonly used for treating arthritis, lower back, migraines and other chronic pain ailments.
Cognitive-behavioral Therapy:Cognitive behavioral therapy combines changes in thought and action to empower you to take back your life when struggling with chronic pain.
Biofeedback: This powerful tool enables your brain to learn strategies for “tuning out” pain similar to tuning out conversations in a noisy restaurant or your wife when she’s interrupting the game.
Does testicular pain impact my fertility?
The short answer is maybe. Testicular pain in its own right does not impact the testicle’s ability to produce sperm. However, many of the underlying causes such as inflammation, infection, varicocele and the like can have a significant impact on fertility. If you are considering fatherhood in the future, it is important to bring up fertility concerns with your urologist. They can order a semen analysis to review your current fertility as well as take steps to ensure treatment preserves reproductive function.
Diagnosing Groin Pain
A proper diagnosis of the underlying cause of testicular pain is important for selecting an effective treatment option. Due to the variety of causes and relatively small structures involved, the process can be frustrating for both doctor and patient. Be patient with your body and your doctor if a cause is not easily identified. Also, advocate for yourself. Get a second opinion or see a specialist if initial treatments are ineffective.
When to go in & How to Choose a Doctor
Primary care docs are the first line of defense. They can evaluate and treat the most common causes of testicular pain. If you have a relationship with a urologist already, they are more specialized in treating conditions of the reproductive and urinary tract and can perform more invasive treatments if necessary. In tough cases, the general urologist may refer you to a urologist who has more specialty training in the treatment of testicular pain. He may also bring in pain specialists, acupuncturists or psychologists to offer a more holistic approach. If your pain is acute, then you should make your way to the emergency room to rule out testicular torsion.
Checklist: Things to Discuss during your Appointment
Going to the doctor to discuss testicular pain is awkward at best. Due to the breadth of causes, it can also be difficult to diagnose. Being prepared can help you feel less awkward and more confident as well as help your doctor focus in on the most likely suspects. Here is a list of items that you will want to review with your doctor:
- How long have you had the pain?
- Is the pain sharp or dull?
- Is the pain constant or occur only during certain activities?
- When did it start? Did anything happen?
- Could you have been exposed to any sexually transmitted infection?
- Have you noticed swelling, shrinkage, lumps, bumps or other changes to the testicle?
- Have you had any other symptoms, such as nausea, fever, pain in other places, difficulty with erection, etc?
- Do you have any history of issues, such as poorly descended testicle, past infection, injury, or surgery?
The Exam: What to Expect
If you are a little anxious about what the exam may be like, the first thing to note is that it should not hurt. First, the doctor will take a complete medical history. Often this will be filling out forms while waiting. Additionally, when the doctor comes in, the first thing he will do is ask what’s wrong. This is a good time to go through the list. Next, the doctor will complete a comprehensive physical exam to look for any abnormalities in the reproductive organs or lower abdomen.
Penis examination: Examine the penis for signs of infection or other abnormalities.
Testicle examination: Feel each testis to make sure it has properly descended as well as search for bumps, swelling and identify areas of tenderness if any. It is important to take a finger and show you doctor where the pain is.
Turn your head and cough: What’s this about? It’s called valsava maneuver and creates pressure in the abdomen which helps the doctor check for an inguinal hernia.
Cremaster reflux: The doctor will touch the inner thigh to provoke the cremaster reflex (the muscle that pulls up the testicles when they get cold) make sure it is working properly.
Abdominal examination: Examine the lower abdomen for signs of inguinal hernia and other abdominal issues.
Rectal exam: The doctor may also perform a rectal exam to identify potential issues with the prostate or the lower GI tract.
Additional Diagnostic Tests
Your doctor may order additional diagnostic tests if he suspects infection, inflammation, hernia or a testicular mass
Urine analysis: A urine sample is often collected to screen for sexually transmitted and urinary tract infections. If there is blood in your urine, it may require a visit with your urologist.
Imaging: Depending on the outcome of the physical exam, the physician may order follow up imaging to get images of the internal structures of the testicle or abdomen. Commonly ordered tests include
Treatment Options for Testicular Pain
Treating chronic testicular pain
Treatment for testicular pain is strongly dependent on the underlying cause. The goal of physicians is to treat conditions that can impact future function of the testicle (such as STIs) and to reduce pain with the least invasive intervention possible. Because of this they will focus first on conservative treatment options before considering more invasive procedures.
Athletic supporters and other custom support systems have shown to be effective at reducing testicular pain. There are also specially designed underwear that provide additional support or have cooling inserts that can provide relief, particularly following a surgical procedure. Some men find constrictive underwear increases problems and experience relief when switching to something a little less restrictive.
Antibiotics: A large portion of cases of persistent testicular pain is caused by infection of the testicle, epididymis or prostate and can be resolved with a combination of antibiotics and anti-inflammatory medications.
Anti-inflammatory: Due to widespread impact of inflammation on the body, modern medicine has developed a host of anti-inflammatory medications which work by acting on various parts of the immune response. Anti-inflammatories are usually employed when the initial infection is taken care of or when an infection is not present. Over-the-counter medications such as ibuprofen (Advil) and aspirin are usually the first step. Doctors can prescribe higher doses of these drugs, collectively knowns as nonsteroidal anti-inflammatory drugs (NSAIDs), to reduce inflammation and pain. If NSAIDs are ineffective, stronger steroidal anti-inflammatories may be prescribed.
Pain Management: In cases with no inflammation or when anti-inflammatories are ineffective, a doctor may consider pain management medications that work by interfering with the pain signals at the nerve or in the brain. There is also a long list of medications designed to reduce pain signals. It may be useful to bring in a pain management specialist who can recommend medications to optimize relief and minimize side-effects. These medications may be good for acute pain, but they might not be a good long-term option since there are excellent non-invasive treatments for management of the pain.
Antidepressants: As mentioned above, depression, anxiety or stress can sometimes accompany or cause testicular pain. Mood medications may provide a helpful reset of brain chemistry but should be prescribed in consultation with a psychiatrist.
Nerve Block: Many patients have found tremendous relief from a nerve block – an injection of local anesthesia directly into the nerves of the spermatic cord to target nerves that travel in and around the spermatic cord. Nerve blocks can also be done higher up in the groin and abdomen. There are quite a few types of medications that your doctor can try, using a combination of steroids and anesthetics.
There are algorithms for the management of testicular pain. First the doctor will maximize conservative therapy (meds, rest, ice, physical therapy). A block can then be performed to see if you get a response. From there, surgical options may be recommended based on the predicted etiology of the pain. It’s important to visit a center where they manage this condition frequently.
In some cases, where the source of pain is clear, surgery may be recommended. It is important to recognize that surgery may not completely resolve the issue, but many men find relief. If you are considering a surgical option, it is important to do a little homework to find a urologist who performs these surgeries routinely. Look for doctors who talk about “micro-surgery” or “robotic surgery” which means that they use a microscope and or robotic assistance during surgery to improve precision. Many of these doctors report that they specialize in male fertility or vasectomy reversal. Some even specialize particular in cases of testicular pain.
Varicocele repair: Varicocele repair is a straight forward procedure to cut off or cut out the thickened veins. In addition to reducing pain and heaviness associated with the varicocele, repair can also improve testicular function showing increases in sperm production, sperm health and testosterone production.
Vasectomy reversal: For vasectomized men whose pain stems from a congested epididymis, a vasectomy reversal may be an effective way at stopping pain. It is particularly important to find a skilled surgeon to reverse a vasectomy as the tubes in question are very small.
Removal of testicular masses: If the pain stems from a spermatocele, hydrocele, cyst or other masses, removal may be effective. In the case of testicular cancer, a partial or complete removal of the testicle is recommended.
Microsurgical denervation of the spermatic cord: For more difficult cases, there may be an option to surgically remove or deaden the nerve in the spermatic cord. Of all the surgeries listed, this may be the most complicated. If you are at the point of considering this as a treatment option, then take the time to find the right doctor.
Testicle removal: It has to be said. Removing the testicle is considered as a last resort for chronic pain.
- If you are considering future paternity, you will need to collect sperm samples to to store in a sperm bank.
- A minority of men experience a phenomenon known as phantom pain. Similar to amputees who lose a limb, men who remove a testicle may still experience pain in the empty place where it once was.
Even considering the above two points, if the pain is debilitating and you have run down the line of other treatment options, it may be worth considering.
Living with Groin Pain
You are not alone. There are about 100,000 new cases of chronic orchialgia every year. It is important to keep your head up, get creative, talk to your loved ones, and explore options.There are many online forums where men are sharing experiences and things they are trying. No two people are alike and at the end of the day, you have to find the solution that is right for you.
J Androl. 2012 Jan-Feb;33(1):22-6. doi: 10.2164/jandrol.110.010991. Epub 2011 Mar 24. A novel treatment of chronic orchialgia. Basal S1, Ergin A, Yildirim I, Goktas S, Atim A, Sizlan A, Irkilata HC, Kurt
E, Dayanc M. Curr Opin Urol. 2010 Jan;20(1):75-9. doi: 10.1097/MOU.0b013e3283337aa0. Robotic surgery in male infertility and chronic orchialgia. Parekattil SJ1, Cohen MS.
Clinical management of chronic testicular pain. Eur Urol. 2004 Apr;45(4):430-6. Chronic testicular pain: an overview. Granitsiotis P1, Kirk D.Am
Fam Physician. 2013 Dec 15;88(12):835-40. Testicular torsion: diagnosis, evaluation, and management. Sharp VJ1, Kieran K1, Arlen AM2.
Am Fam Physician. 2014 May 1;89(9):723-7. Evaluation of scrotal masses. Crawford P1, Crop JA1. Saudi J Anaesth. 2014 Apr-Jun; 8(2): 294–298. doi: 10.4103/1658-354X.130755 Ultrasound-guided pulsed radiofrequency ablation of the genital branch of the genitofemoral nerve for treatment of intractable orchalgia Abdullah Sulieman Terkawi and Kamel Romdhane1
Can Urol Assoc J. 2015 Jan-Feb;9(1-2):e72-4. doi: 10.5489/cuaj.2383. Early experience with microsurgical spermatic cord denervation for chronic orchialgia at a Canadian centre. Cassidy DJ1. Am J Mens Health. 2013 Sep;7(5):402-13. doi: 10.1177/1557988313476732. Epub 2013 Feb 11. Chronic testicular pain in adult men: an integrative literature review. Quallich SA1, Arslanian-Engoren C.
Postgrad Med. 1995 Oct;98(4):151-3, 156-8. Chronic testicular pain. A workup and treatment guide for the primary care physician Baum N1, Defidio L.
Aust Fam Physician. 2013 Nov;42(11):790-2. Acute scrotal pain. Srinath H1.
AJR Am J Roentgenol. 2001 Jun;176(6):1459-66. Tuberculous epididymitis and epididymo-orchitis: sonographic appearances. Muttarak M1, Peh WC, Lojanapiwat B, Chaiwun B.
Can J Urol. 2012 Apr;19(2):6160-4. Post-vasectomy pain syndrome: clinical features and treatment options. Morley C1, Rogers A, Zaslau S.
Am Fam Physician. 2009 Apr 1;79(7):583-7. Epididymitis and orchitis: an overview. Trojian TH1, Lishnak TS, Heiman D.
Am Fam Physician. 1998 Feb 15;57(4):685-92. Testicular masses. Junnila J1, Lassen P.
Sex Transm Infect. 2004 Feb;80(1):12-7. Genital manifestations of tropical diseases. Richens J1.
J Infect Dev Ctries. 2015 Mar 18;9(5):456-62. doi: 10.3855/jidc.5346. Filarial hydrocele: a neglected condition of a neglected tropical disease. Otabil KB1, Tenkorang SB.
BJU Int. 2003 Mar;91(5):435-7. The aetiology, pathophysiology and management of chronic orchialgia. Masarani M1, Cox R.
Am Fam Physician. 2009 Apr 1;79(7):583-7. Epididymitis and orchitis: an overview. Trojian TH1, Lishnak TS, Heiman D.
Springerplus. 2014 Feb 21;3:107. doi: 10.1186/2193-1801-3-107. eCollection 2014. Hernioplasty and testicular perfusion. Dilek ON
Ann Surg. 2001 Jan; 233(1): 8. Groin Pain After Hernia Repair Robert E. Condon, MD, MS, FACS
J Am Coll Surg. 2004 Feb;198(2):181-4. Testicular pain after inguinal hernia repair: an approach to resection of the genital branch of genitofemoral nerve. Ducic I1, Dellon AL.
Br J Surg. 2007 Jan;94(1):17-22. Nerve management during open hernia repair. Wijsmuller AR1, van Veen RN, Bosch JL, Lange JF, Kleinrensink GJ, Jeekel J, Lange JF.
Pediatrics. 2000 Oct;106(4):843. “Blue balls”: A diagnostic consideration in testiculoscrotal pain in young adults: A case report and discussion. Chalett JM1, Nerenberg LT.
Ther Adv Urol. 2010 Oct-Dec; 2(5-6): 209–214. Chronic orchialgia: evaluation and discussion of treatment options Laurence Levine,
Psychol Res Behav Manag. 2011; 4: 41–49. The role of psychological interventions in the management of patients with chronic pain Daniela Roditi and Michael E Robinson