Pediatric Testicular Pain: A Comprehensive Review of Etiology, Diagnostic Approaches, and Management Strategies

Purpose of Review: Pediatric orchialgia (testicular or scrotal pain) spans a spectrum from surgical emergencies such as testicular torsion to benign, self-limited conditions. Swift, accurate triage is essential to preserve testicular viability and future fertility Leslie et al. (2025). To synthesize contemporary evidence on the incidence, etiologies, clinical presentation, diagnostic work-up, and management of the principal causes of pediatric testicular pain and to provide an evidence-based framework for clinicians. A narrative literature review was performed, emphasizing peer-reviewed studies and guideline statements published in the past five years, supplemented by seminal earlier works where recent data were lacking. Key topics included testicular torsion, torsion of the appendix testis, epididymitis/epididymo-orchitis, varicocele, inguinal hernia/hydrocele, and epididymal cysts. Recent Findings: Testicular torsion remains the critical diagnosis, with an incidence of 3.8–5.9 per 100,000 males < 17 years and accounting for roughly 30–40% of acute scrotum presentations Chanchlani (Cureus. 2023;15(3):e36259, 2023), Keefe et al. (Can Urol Association J. 18(6):E332–7, 2024). Salvage exceeds 80% when detorsion occurs within six hours but plummets thereafter Ringdahl et al. (Am Fam Physician 74(10):1739–1743, 2006), Brenner (n.d.). Doppler ultrasonography is the first-line imaging modality; absent or markedly decreased intratesticular flow reliably differentiates torsion from mimics while rarely delaying intervention Ringdahl et al. (Am Fam Physician 74(10):1739–1743, 2006). Torsion of the appendix testis, more prevalent than true torsion in school-age boys, is self-limiting and managed with analgesia and observation once testicular perfusion is confirmed Kim et al. (Am J Emerg Med. 36(7):1302–3, 2018). Epididymitis shows an age-dependent etiology. Urinary anomalies predominate in prepubertal cases, whereas sexually transmitted infections lead in adolescents, guiding laboratory evaluation and antibiotic selection Merlini et al. (Scand J Urol Nephrol. 32:273, 1998). Varicocele affects 10–15% of adolescent males; intervention is reserved for testicular asymmetry, pain, or suspected subfertility risk de los Reyes (Can Urol Association J. 11(1–2 Suppl1):S34–9), 2017), Leslie (2025). Inguinal hernias and communicating hydroceles mandate timely elective repair to forestall incarceration, whereas simple hydroceles and most epididymal cysts warrant observation Ringdahl et al. (Am Fam Physician 74(10):1739–1743, 2006), Poenaru et al. (Paediatr Child Health. 5(8):461–2, 2000), Cai et al. (Front Pead. 12:1455866, 2024). Summary: A structured, etiology-focused approach centered on rapid exclusion of torsion, judicious use of ultrasound, and condition-specific management optimizes outcomes in children with testicular pain.