Questionnaire/history: Pain? - Site (eg unilateral or bilateral)? - Speed of onset (eg rapid)? - Severity? Swelling? Previous episodes of severe, self-limiting pain and swelling (described by some men and boys with testicular torsion)? Associated symptoms? - Nausea, vomiting (common with torsion, may occur with epididymo-orchitis)? - Symptoms of a lower urinary tract infection? - Urethral discharge (suggesting epididymo-orchitis)? - Parotid swelling (suggesting mumps orchitis)? - Back pain, breathlessness or weight loss (may occur in metastatic testicular cancer)? - Other? Sexual history (if appropriate)? History of trauma (in haematocele and, rarely, testicular torsion) or strenuous physical activity? Past medication history? Current medication? Drug allergies? Examination: Position of any swelling in relation to the testis (testicular, extra-testicular)? Testicular lie (suspect testicular torsion if high-riding or transverse)? Size of the testis (may be enlarged with a testicular tumour)? Symmetry of the testes, (in torsion the epididymis may be located anteriorly)? Tenderness (present in torsion and epididymo-orchitis)? Consistency of any swelling (for example, solid with testicular cancer, soft with a hydrocele)? Lymphadenopathy? Abdominal mass? Prehn sign (relief of pain with elevation of the testes - may suggest epididymitis, but does not rule out testicular torsion)? Transillumination (indicative of hydrocele)? Features of inguinal hernia (examine the person both lying and standing) (eg palpable bulge in the inguinal canal, positive cough impulse)? Skin changes (eg raised papule, plaque or ulcer suggesting scrotal cancer (extremely rare), erythema (associated with epididymo-orchitis) or bluet dot sign, where an inflamed and ischaemic torsed appendage can be seen through the scrotal skin)? Differential diagnosis of scrotal pain and swelling: Testicular torsion, torsion of appendix testis or appendix epididymis, epididymo-orchitis, testicular cancer Differential diagnosis of extra-testicular causes of scrotal swelling: Epididymal cyst or spermatocele, varicocele, hydrocele, haematocele, indirect inguinal hernia, squamous cell carcinoma of the scrotum Management: According to cause Reference(s): NICE CKS: Scrotal pain and swelling