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Testicular Pain - Causes and Treatment

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Step 1 - Rule Out Emergencies

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Step 2 - Common Causes and Their Medicines

1. Epididymitis / Orchitis (Infection - Most Common Cause of Testicular Pain)

• Sexually active men (STI suspected, age <35):
  • Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg orally twice daily for 10 days
• Men who also practice insertive anal sex (STI + enteric organisms):
  • Levofloxacin 500 mg orally once daily for 10 days
  • OR Ofloxacin 300 mg orally twice daily for 10 days
• Older men / urinary tract source (enteric bacteria, no STI):
  • Levofloxacin 500 mg orally once daily for 10 days
  • OR Ciprofloxacin (dose by culture sensitivity)

• NSAIDs (ibuprofen, naproxen) for pain and inflammation
• Bed rest, scrotal elevation, cold packs to the scrotum

Note: If symptoms don't improve within 72 hours, re-evaluation with ultrasound is recommended to rule out abscess or missed torsion. - Campbell-Walsh-Wein Urology

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2. Viral Orchitis (Mumps, EBV, HIV)

• Mumps orchitis: Interferon-alpha (partially effective, does not always prevent testicular atrophy)
• Pain relief: NSAIDs + scrotal support
• Most viral orchitis resolves in 1-4 weeks; no specific antiviral cures it

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3. Autoimmune Orchitis

• Corticosteroids (prednisone)
• Immunosuppressants (azathioprine, cyclophosphamide)
• Intravenous immunoglobulin (IVIG) in severe cases

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4. Chronic Orchialgia / Chronic Scrotal Pain Syndrome (pain >3 months)

"Medical treatments lack evidence-based studies. Many types of medications have been used including antibiotics, anti-inflammatories, phytotherapy, and anxiolytics." - Campbell-Walsh-Wein Urology, p. 1578

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5. Referred Pain (kidney stone, hernia, lumbar disk)

• Treat the underlying cause (stone: pain relief + expulsion therapy; hernia: surgical repair)
• NSAIDs or antispasmodics (tamsulosin for ureteral stones)

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6. Tuberculous Epididymo-orchitis

• Standard 4-drug anti-TB regimen (rifampicin + isoniazid + pyrazinamide + ethambutol) for 6 months
• Following EAU guidelines

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General Symptomatic Relief (All Causes)

1. Ibuprofen 400-600 mg every 6-8 hours with food (most accessible first-aid)
2. Scrotal support (supportive underwear)
3. Cold compresses for acute swelling
4. Rest and avoid heavy lifting

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Bottom Line

• Sudden severe pain = ER now (possible torsion)
• Gradual pain + fever + swelling = likely infection, needs antibiotics (see a doctor for culture/STI testing)
• Long-standing dull ache = chronic orchialgia, requires urology workup before long-term treatment
• Ibuprofen alone provides symptom relief but does NOT treat the underlying cause

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Medical Abortion at 40 Days (About 6 Weeks of Pregnancy)

Important: 40 days of pregnancy = approximately 6 weeks (within first trimester). Medical abortion at this stage is safe, highly effective (~97%), and well-supported by WHO and international guidelines. However, this must be done under medical supervision. Please see a doctor, gynecologist, or registered clinic.

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Standard Regimen (WHO / FDA Approved)

Drug 1 - Mifepristone (RU-486)

• Dose: 200 mg orally (1 tablet), taken by mouth
• What it does: Blocks progesterone, a hormone needed to maintain pregnancy
• Brand names in India: Mifeprin, Mifegest, MTP Kit

Drug 2 - Misoprostol (taken 24-48 hours after Mifepristone)

• Dose: 800 mcg (four 200 mcg tablets)
• Route: Placed under the tongue (sublingual), inside the cheek (buccal), or vaginally
• What it does: Causes uterine contractions to expel the pregnancy
• Brand names in India: Cytolog, Misoprost, or combined as MTP Kit

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How It Works (Step by Step)

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Effectiveness at 40 Days

• At 6 weeks (40 days): ~97-98% effective - no surgical procedure needed
• The earlier the gestational age, the higher the success rate
• If incomplete (rare), a minor surgical procedure (MVA/D&C) may be needed

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Side Effects to Expect

• Normal: Heavy bleeding (heavier than a period), cramping/pain, passing clots, mild nausea, diarrhea
• Pain relief: Ibuprofen 400-600 mg or paracetamol can be taken for cramps

When to Go to the ER Immediately

• Soaking more than 2 pads per hour for 2+ consecutive hours
• Fever above 38°C lasting more than 24 hours after taking misoprostol
• Severe abdominal pain not relieved by painkillers
• No bleeding at all within 24 hours of misoprostol

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Misoprostol-Only Option (if Mifepristone is not available)

• Misoprostol alone: 800 mcg sublingually or vaginally, repeated after 3 hours if needed
• Effectiveness is lower (~80-85%) compared to the combination regimen

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Legal Note (India)

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Clinical Reference Guide: Early Pregnancy Termination

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1. Overview and Safety Profile

• Overall mortality rate: 0.7 per 100,000 procedures (legal abortion)
• Risk increases exponentially with gestational age
• Mortality with aspiration at ≤8 weeks: 0.3 per 100,000; at ≥18 weeks: 6.7 per 100,000
• For comparison, maternal mortality from continued pregnancy: 8.8 per 100,000 live births
• 88% of legal abortions are performed in the first trimester

"Legal abortion remains an extremely safe procedure... Nevertheless, in comparison to a maternal mortality rate of 8.8 deaths per 100,000 live births, abortion by D&E beyond 18 weeks' gestation is safer than continuing pregnancy." - Berek & Novak's Gynecology

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2. Pre-Procedure Assessment

2a. History and Workup

Routine ultrasonography is not required for every patient but is mandatory when LMP is uncertain, there is a size/dates discrepancy, or risk factors for ectopic pregnancy exist.

2b. Contraindications to Medical Abortion (Mifepristone/Misoprostol)

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3. Methods of Early Pregnancy Termination

Overview: Method by Gestational Age

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4. Medical Abortion

4a. Regimen 1 - Mifepristone + Misoprostol (First-Line, Preferred)

• Mifepristone: Progesterone receptor antagonist - causes decidual necrosis and sensitizes the uterus to prostaglandins
• Misoprostol: Synthetic PGE1 analogue - causes uterine contractions and expulsion

• Buccal route: Place 4 x 200 mcg tablets between gum and cheek; absorb for 30 min, swallow remnants
• Sublingual route: Higher bioavailability; more GI side effects
• Vaginal route: Can be used 0-72 hours after mifepristone with equivalent efficacy

"The evidence-based regimen of mifepristone 200 mg orally followed by a single dose of buccal misoprostol 800 mcg 24 to 48 hours later results in a 99.6% efficacy of pregnancy termination." - Tintinalli's Emergency Medicine

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4b. Regimen 2 - Methotrexate + Misoprostol (Alternative)

• Used when mifepristone is unavailable
• Methotrexate 50 mg/m² IM followed by misoprostol 800 mcg vaginally 3-7 days later
• Works over weeks rather than days; requires multiple visits
• Efficacy: ~90-95% (lower than mifepristone regimen)
• Key advantage: Treats concurrent early ectopic pregnancy; mifepristone/misoprostol does NOT
• Use limited to pregnancies <8 weeks gestation

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4c. Regimen 3 - Misoprostol Only

• Used where mifepristone is unavailable or legally restricted
• Misoprostol 800 mcg sublingually or vaginally, repeated every 3 hours x 3 doses if needed
• Efficacy: ~80-85% (significantly lower than combination regimen)
• Higher side effect burden (nausea, diarrhea, chills, fever)
• WHO supports this as an acceptable alternative when combination not available

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4d. Patient Instructions and Follow-Up

1. Cramping begins within 1-4 hours
2. Heavy bleeding with clots - usually peaks at 2-6 hours
3. Bleeding decreases to spotting over 1-3 weeks; may continue until next menses
4. Pain management: Ibuprofen 600-800 mg + codeine or tramadol for moderate-severe pain

• Confirm complete abortion by:
  • Transvaginal ultrasound (absence of gestational sac), OR
  • Serial serum hCG (>80% decline from baseline at 1 week confirms success)
• Address ongoing contraception

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5. Surgical Abortion

5a. Manual Vacuum Aspiration (MVA)

• Gestational age: 4-10 weeks
• Setting: Outpatient clinic or office; local anesthesia (paracervical block) ± sedation
• Technique: Cannula (5-12 mm) attached to 50 mL modified syringe; vacuum generated manually
• Equally effective as electric vacuum up to 10 weeks
• Efficacy: >98%
• Cervical preparation: Misoprostol 400 mcg vaginally or buccally 3-4 hours before procedure OR osmotic dilators (laminaria)
• Antibiotic prophylaxis: Doxycycline 100 mg the night before (single dose) - recommended by Society of Family Planning

5b. Electric Vacuum Aspiration (EVA) / Suction Curettage

• Gestational age: Up to 12-13 weeks
• Setting: Clinic, office, or day surgery
• Technique: Electric pump with plastic cannula; larger cannula sizes used with advancing gestation
• Cervical dilation: Progressive dilators or misoprostol pre-treatment
• Efficacy: >98-99%
• One to two visits; procedure typically takes 5-10 minutes

5c. Dilation and Evacuation (D&E)

• Gestational age: 13-24 weeks (second trimester)
• Setting: Outpatient surgical facility; regional or general anesthesia
• Cervical preparation: Osmotic dilators (laminaria/Dilapan-S) placed 4-24 hours before, with or without misoprostol
• Considered safer than medical induction for second-trimester termination

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6. Complications

6a. Medical Abortion Complications

"A higher frequency of complications occurs in medical induction versus surgical abortion, most notably infection and retained placenta." - Tintinalli's Emergency Medicine

6b. Surgical Abortion Complications (First-Trimester Aspiration)

6c. Complication Timeline

6d. Red Flag Symptoms - When to Seek Emergency Care

• Soaking >2 sanitary pads/hour for 2+ consecutive hours
• Fever >38°C persisting >24 hours after misoprostol
• Severe abdominal pain unresponsive to NSAIDs
• No bleeding within 24 hours of misoprostol administration
• Signs of sepsis: rigors, hypotension, tachycardia

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7. Special Clinical Considerations

7a. Rh-Negative Patients

• All Rh-negative patients must receive Rh₀(D) immunoglobulin (RhIG)
• Dose: 300 mcg IM within 72 hours of the procedure
• If not given within 72 hours, risk of sensitization in a subsequent pregnancy is ~3%
• Smaller dose (50 mcg / MICRhoGAM) acceptable for gestations <12 weeks

7b. IUD in Situ

• IUD must be removed before initiating medical abortion
• If removal cannot be done without delaying treatment, proceed with uterine aspiration instead

7c. Previous Cesarean Section

• Mifepristone/misoprostol regimen does not require dose adjustment for one prior CS
• For patients with ≥2 prior CS at higher gestational ages (≥24 weeks): consider reducing misoprostol doses (individualize care)

7d. Ectopic Pregnancy - Critical Safety Point

• Neither mifepristone/misoprostol NOR misoprostol alone treats ectopic pregnancy
• Methotrexate is the appropriate medical treatment for ectopic pregnancy
• Always rule out ectopic before initiating any medical abortion regimen - ultrasound confirmation of intrauterine pregnancy is mandatory when risk factors are present

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8. Comparison of Methods at a Glance

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9. Post-Procedure Contraception

• IUD (copper or levonorgestrel): Can be inserted immediately after surgical aspiration or at follow-up after medical abortion
• Implant: Can be inserted on Day 1 (with mifepristone) or at follow-up
• Combined OCP / progestogen-only pill: Can start same day as mifepristone
• DMPA injection: Can give on Day 1 or at follow-up
• Barrier methods: Available immediately

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10. Key Drug Reference

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• Berek & Novak's Gynecology, 16th Ed. - Chapter 14 (Contraception and Abortion)
• Goldman-Cecil Medicine, International Ed. - Medication Abortion section
• Tintinalli's Emergency Medicine, 9th Ed. - Chapter 105 (Induced Abortion)
• Pfenninger & Fowler's Procedures for Primary Care, 3rd Ed. - Chapter 128
• ACOG Committee Statement No. 13: Self-Managed Abortion (2024) - PMID 39601716
• Society of Family Planning Clinical Recommendation: Medication management for early pregnancy loss (2025) - PMID 39710335