Scrotal pain is a common urological emergency and a significant cause of morbidity in males of all age groups. It can present as acute or chronic and is associated with a wide range of etiologies ranging from benign and self-limiting conditions to life-threatening surgical emergencies such as testicular torsion [1]. Accurate and timely diagnosis is essential because the clinical presentation of different conditions often overlaps, and delays in treatment, especially in cases like torsion, can result in testicular loss and infertility [2].

The causes of scrotal pain are diverse and include testicular torsion, epididymo-orchitis, hydrocele, pyocele, hematocele, varicocele, inguinoscrotal hernia, trauma, tumors, and scrotal cellulitis [3]. Differentiating among these conditions on clinical grounds alone may be challenging due to nonspecific findings, particularly in pediatric and adolescent age groups where history-taking can be limited [4].

Ultrasonography (USG) with color Doppler has emerged as the imaging modality of choice for evaluating scrotal pathology. It is non-invasive, widely available, cost-effective, and provides real-time assessment of scrotal contents. Doppler sonography, in particular, is invaluable in distinguishing vascular from non-vascular causes of scrotal pain and in differentiating torsion from inflammatory conditions [5,6]. Studies have shown that scrotal USG has a sensitivity and specificity exceeding 90% in diagnosing testicular torsion and epididymo-orchitis [7].

Clinical evaluation remains the cornerstone of diagnosis, but when combined with ultrasonography, it enhances diagnostic accuracy, reduces unnecessary surgical explorations, and guides appropriate management [8]. Moreover, structured outcome measures such as the Karnofsky Performance Status Scale (KPSS) can be employed to assess the functional impact of scrotal diseases and monitor recovery following treatment [9].

In India, where scrotal pain is a frequent presenting complaint in surgical and emergency departments, there is limited published literature on the clinical spectrum and ultrasonographic correlation of this condition. Hence, this study was undertaken to evaluate the clinical profile of scrotal pain, correlate it with ultrasonographic findings, and assess treatment outcomes among patients presenting to a tertiary care hospital.

MATERIALS AND METHODS

Study Design and Setting

This was an observational, prospective study conducted in the Department of Surgery, Santosh Medical College & Hospital, Ghaziabad, Uttar Pradesh. The study was carried out among male patients presenting with scrotal pain referred for ultrasonographic evaluation.

Study Area and Duration

The study was conducted in District Ghaziabad (Uttar Pradesh), India, over a period of 18 months (November 2018 to April 2020).

Study Population and Sample Size

A total of 100 male patients of all age groups presenting with acute or chronic scrotal pain were enrolled. Sample size was calculated using OpenEpi v3.0 based on findings of Rottenstreich M. et al. (2017), which reported that 6.2% of patients required surgical management for scrotal pain among 382,036 medical records. With a 95% confidence interval (CI) and design effect = 1, the minimum sample size was estimated to be 90. To compensate for potential non-responders and loss to follow-up, an additional 10% was added, rounding the final sample to 100 patients. Patients were selected using a convenience sampling method (i.e., first-come, first-served basis).

Inclusion Criteria

1. Male patients of all age groups reporting with acute or chronic scrotal pain.
2. Patients willing to participate in the study.
3. Patients consenting to undergo ultrasonography of the scrotum.

Exclusion Criteria

1. Patients with open wounds in the scrotum.
2. Patients with bleeding disorders.
3. Patients absconding before complete clinical evaluation and treatment.
4. Patients not willing to provide informed consent.

Ethical Considerations

Approval was obtained from the Institutional Ethical Committee prior to commencement of the study. Written informed consent was taken from all participants after explaining the aim, objectives, and procedures of the study. Participation was voluntary, and confidentiality of patient data was ensured.

Method of Data Collection

Each participant underwent detailed history-taking and clinical examination. Data regarding demographic profile, occupation, socio-economic status, presenting complaints, duration and onset of pain, side of involvement, associated symptoms, and past medical history were recorded in a pre-designed case history proforma.

Functional impairment was assessed using the Karnofsky Performance Status Scale (KPSS). Clinical findings were further correlated with ultrasonography (USG) of the scrotum with Doppler studies where required.

Clinical and Diagnostic Evaluation

1. Initial Evaluation – All patients underwent general physical, systemic, and local examination.
2. Basic Investigations – Complete blood count (CBC), bleeding time (BT), clotting time (CT), renal function tests (RFTs), and viral markers were performed. ECG, echocardiography, and chest X-ray were done if clinically indicated.
3. Radiological Assessment – Ultrasonography of the scrotum and abdomen was performed for all patients. Doppler studies were conducted as needed.
4. Treatment – Based on clinical diagnosis and USG findings, patients were managed accordingly. Cases of acute epididymo-orchitis were treated conservatively, while surgical intervention was performed in indicated cases.
5. Postoperative Monitoring – Patients undergoing surgery were observed in the postoperative period for complications.
6. Follow-up – Patients were followed up clinically at three intervals: 7 days, 15 days, and 30 days after the first visit. KPSS was reassessed at each follow-up to evaluate functional improvement.

Statistical Analysis

Data were entered in Microsoft Excel and analyzed using SPSS version 24.0 (IBM Corp., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation (SD) and categorical variables as frequency and percentage. Comparisons between groups were made using the Student’s t-test for continuous variables and the Chi-square test for categorical variables. For non-parametric data, results were presented as median (minimum–maximum), and statistical significance was tested using appropriate non-parametric tests. A p-value <0.05 was considered statistically significant.

RESULTS AND OBSERVATIONS

The study was carried out among 100 patients of scrotal pain of any age group who voluntarily consented to be a part of the study. In this study, clinical profiling of various causes of scrotal pain was clinically and ultrasonologically evaluated. The present study was a Randomized, Prospective study conducted in Santosh Medical College & Hospital, Ghaziabad (Uttar Pradesh).

Table 1: Demographic and Clinical Profile of Study Participants (N = 100)

Table 2: Clinical Profile of Scrotal Pain among Study Participants (N = 100)

Table 3: Clinical Symptoms among Study Participants (N = 100)

Table; 4 Clinical, Laboratory, and Imaging Findings among Study Participants (N=100)

Figure 1: Final diagnosis of acute scrotal pain among study participants

Table; 5 Treatment Modalities and Outcomes among Study Participants (N=100)

Table 6: Comparison of clinical diagnosis with onset of pain:

Table 7: Comparison of clinical diagnosis with presence of fever:

Table 8: Comparison of clinical diagnosis with clinical condition:

Table: 9 Comparison of KPSS Score with Demographic Variables

DISCUSSION

The present prospective study evaluated 100 patients presenting with scrotal pain and correlated clinical findings with ultrasonographic results. The majority of patients (63%) belonged to the 21–40 years age group, with a mean age of 27 years, indicating that scrotal disorders are more common among young and sexually active males. This is in agreement with previous studies by Srinivasan et al. [1] and Lewis et al. [2], who reported a peak incidence in adolescents and young adults.

In our study, gradual onset of pain (91%) was more common than sudden onset (9%). Testicular torsion was significantly associated with sudden onset pain (p=0.004), consistent with the findings of Kapoor [3] and Barada et al. [4], who emphasized that sudden severe pain is a diagnostic hallmark of torsion and necessitates immediate surgical exploration to prevent testicular loss.

Epididymo-orchitis (27%) was the most frequent diagnosis, followed by inguinoscrotal hernia (25%) and hydrocele (16%). Epididymo-orchitis was significantly associated with fever and urinary symptoms (p=0.021), supporting an infective etiology, as also highlighted by Street and Wilson [5]. Hydrocele and hernia were largely associated with chronic, painless or mildly painful swelling, in agreement with Dogra et al. [6].

Ultrasonography with Doppler was pivotal in differentiating between torsion, infection, and other scrotal pathologies. In our study, 27 patients had enlarged epididymis with increased vascularity (suggestive of epididymo-orchitis), 7 had absent/reduced vascularity (torsion), 16 had hydrocele, and 9 had varicocele. These findings are in line with Kalfa et al. [7] and Munden et al. [8], who reported that Doppler ultrasonography has high sensitivity and specificity (>90%) in distinguishing torsion from inflammatory causes of scrotal pain.

Management in our study revealed that 62% required surgical intervention, while 38% were treated conservatively. The most common surgeries were hernia repair (37%) and hydrocele surgery (26%), whereas torsion cases required orchidopexy or orchidectomy depending on viability. Similar surgical predominance was reported by Anderson and Giacomantonio [9], who highlighted the importance of timely surgery in torsion and complicated scrotal conditions.

Functional outcome, measured using the Karnofsky Performance Status Scale (KPSS), showed significant improvement from admission (61.5 ± 14.2) to 30-day follow-up (90.3 ± 7.8). This underscores the positive impact of appropriate diagnosis and timely intervention on patient recovery and quality of life. Although limited literature exists on KPSS application in scrotal pathology, its utility in quantifying surgical outcomes has been validated in other clinical contexts [10].

Overall, our study reinforces the complementary roles of clinical examination and ultrasonography. Clinical features such as onset of pain, fever, and urinary symptoms provide diagnostic clues, while ultrasonography confirms the diagnosis and guides treatment. Early recognition of surgical emergencies like torsion is crucial, as delays can result in irreversible testicular damage and infertility [11].

CONCLUSION

Scrotal pain has varied etiologies, with clinical overlap making diagnosis difficult. Ultrasonography with color Doppler, when combined with clinical evaluation, provides high diagnostic accuracy, minimizes unnecessary surgical interventions, and ensures timely management. This integrated approach should be the standard for evaluating scrotal pain to improve outcomes and preserve testicular function.

REFERENCES

1. Srinivasan A, Cinman N, Feber KM, Gitlin J, Palmer LS. History and physical examination findings predictive of testicular torsion. J Pediatr Urol. 2011;7(4):470–474.
2. Lewis AG, Bukowski TP, Jarvis PD, Wacksman J, Sheldon CA. Evaluation of acute scrotum in the emergency department. J Pediatr Surg. 1995;30(2):277–281.
3. Kapoor S. Testicular torsion: a race against time. Int J Clin Pract. 2008;62(5):821–827.
4. Barada JH, Weingarten JL, Cromie WJ. Testicular salvage and age-related delay in the presentation of testicular torsion. J Urol. 1989;142(3):746–748.
5. Street JJ, Wilson JL. Acute epididymitis and orchitis: a review of etiology and management. Am Fam Physician. 2008;77(5):583–587.
6. Dogra VS, Gottlieb RH, Rubens DJ, Oka M. Sonography of the scrotum. Radiology. 2003;227(1):18–36.
7. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007;177(1):297–301.
8. Munden MM, Trautwein LM, Donnelly LF. Sonography of pediatric scrotal disorders. Ultrasound Q. 2000;16(3):157–167.
9. Anderson MJ, Giacomantonio JM. The fate of the testis following torsion of the spermatic cord. J Urol. 1985;133(3):434–436.
10. Schag CC, Heinrich RL, Ganz PA. Karnofsky Performance Status revisited: reliability, validity, and guidelines. J Clin Oncol. 1984;2(3):187–193.
11. Cokkinos DD, Antypa E, Kalogeropoulos I, et al. Contrast-enhanced ultrasound of the scrotum: a pictorial review. Insights Imaging. 2013;4(5):723–730.