By: Jacqueline Morin, MD &
Julie Cheng, MD, MAE, FAAP
Pain in the genitals is something that boys of any age may experience. There are many possible causes for pain in the "private area"—the penis, testicles or scrotum. They range from an
injury to less obvious reasons. Some causes are harmless and will get better on their own, while others may need emergency care.
Keep reading to learn some of the most common causes of genital pain and what to do if your child has symptoms.
1. Testicular torsion
Sudden pain in your child's scrotum or testicle might be a condition called "testicular torsion." This happens when the testicle twists on itself, cutting off its blood flow. This usually happens in boys between 12 and 18 years of age, but can happen at any age.
Testicular torsion is a medical emergency and requires surgery right away to restore blood flow and save the testicle.
Symptoms of testicular torsion
The testicular pain may come with abdominal pain and nausea or vomiting. The painful testicle might look higher than usual, rotated sideways, and even swollen, firm or red. An ultrasound in the emergency department will check for blood flow to the testicle, and if there is none, emergent surgery is needed to untwist it. In cases when the testicle is without blood flow for too long, it cannot be saved and needs to be removed.
What is torsion of the appendix testis?
One condition that can mimic testicular torsion, is torsion of the appendix testis. Each testicle has a tiny, finger-like projection attached. These can twist on their own and cause pain that feels like testicular torsion, with sudden pain and swelling in the scrotum. This condition is less likely to have nausea or vomiting, and the testicle will look normal and even with the other testicle. Sometimes a small blue bruise can occur.
A scrotal ultrasound will rule out testicular torsion, and surgery is not needed. The pain will go away on its own with medicine like acetaminophen and ibuprofen. Since this condition looks so much like testicular torsion, it is important to go to the emergency department right away to make sure it is not testicular torsion.
We suggest parents talk with their child about testicular torsion, so they know to tell a parent or caregiver right away if this happens to them. If your child complains of sudden severe testicle pain, go straight to a hospital
emergency department (urgent care does not usually have ultrasound available) for evaluation and possible surgery if they are diagnosed with testicular torsion.
2. Epididymitis & urinary tract infection
The epididymis is a tube that sits upon each testicle. Sometimes it can get inflamed, resulting in a painful condition called "epididymitis."
In younger boys, epididymitis is commonly caused by a backflow of urine from a duct in the urethra to the epididymis, which can irritate it. This can happen when a child holds their urine too long or has trouble peeing. In older boys, epididymitis can result from a bacterial infection, such as a urinary tract infection (UTI) or a sexually transmitted infection (STI).
Symptoms of epididymitis
Boys with epididymitis may notice swelling in one or both sides of the scrotum, pain or burning during urination, and, if it is an STI, milky discharge from the urethra. It is important that boys with these symptoms get their urine tested for a UTI and have a scrotal ultrasound. Sometimes,
STI testing may also be needed.
3. Pelvic floor dysfunction
Pain in the private parts can also happen because of problems with the muscles and nerves in the
pelvic area.
"Pelvic floor dysfunction" is a catch-all term used when there are issues with the muscles that help control the bowel and bladder. Sometimes, these muscles are too weak or tight or have spasms. This can affect the nerves that allow the bladder to function as well as cause pain.
Symptoms of pelvic floor dysfunction: constipation & bladder control issues
Constipation can be a sign of pelvic floor dysfunction. When kids are constipated, large pieces of stool can stretch the rectum, which can irritate the muscles and nerves of the pelvic floor. This can even cause pain in the scrotum or pain with urination.
Some kids may also have trouble emptying their bladders because they can't relax their pelvic floors while peeing (see "Voiding Dysfunction Explained.") This can also cause pain.
In addition to the discomfort, constipation and trouble emptying the bladder can lead to UTIs. So, it is important to treat pelvic floor dysfunction when it's suspected.
Treatment options for pelvic floor dysfunction may include:
pelvic floor physical therapy to relax the pelvic muscles
medicines for constipation
peeing on a regular schedule to make sure the bladder is frequently emptied
4. Kidney stones
A less obvious cause of testicle or penis pain can be from a
kidney stone. As the stone moves down the tube that connects the kidney to the bladder (called the ureter), it can block urine from flowing easily. This blockage stretches the ureter upstream from the stone, which in turn activates nerves that also supply sensation to the testicles. This causes pain in the scrotum.
Symptoms of kidney stones
If your child also has abdominal or side pain, has nausea or vomiting or
blood in the urine, it could mean a stone is passing. In kids, kidney stones usually pass on their own, but sometimes they can get stuck. If your child is unable to keep down fluids, the pain is too much to handle, or they have a fever, you should go to the emergency department.
5. Foreskin issues: phimosis & balanitis
In boys who are
not circumcised, there are some foreskin conditions that can cause pain.
Phimosis
One is called "phimosis", which happens when the foreskin is too tight around the head of the penis and cannot be pulled back. Phimosis is normal in babies and toddlers, but most boys grow out of it by preschool age.
Balanitis xerotica obliterans (BXO)
The foreskin can also get irritated if urine is trapped under it, which can cause a condition called "balanitis xerotica obliterans" (BXO). BXO can make it hard or painful to pull the foreskin back, cause trouble or pain with urination and lead to UTIs. To prevent BXO, it is important to take care of the foreskin by gently pulling it back as far as it can go during potty training and baths. If you notice redness, thick white scarring of the foreskin, skin tearing, bleeding or pain when moving the foreskin, schedule a visit with a pediatrician or pediatric urologist.
Paraphimosis
There are a few other conditions that cause pain and swelling of the penis. One is when the foreskin gets stuck
behind the head of the penis, called "paraphimosis." This is painful because it stops blood from flowing to the head of the penis. The foreskin becomes red and swollen and the head of the penis might turn a red or purple.
Similarly, if a hair or other object gets wrapped tightly around the penis, it can cause pain and swelling. If you see lots of swelling of your child's foreskin, it is important to get checked right away to remove the object or replace the foreskin back to its natural location.
When should my child see a doctor for genital pain?
Genital pain in children can have many causes, so it can be hard to know how serious the problem is. Trust your instincts as a parent and get help if you are worried.
Conditions that need immediate evaluation in an emergency department include sudden severe pain in a testicle and significant pain and swelling of the penis. It is also best to take them to the emergency department right away if your child has other symptoms like abdominal pain, nausea, vomiting or blood in the urine; if they had an injury that significantly hurt the scrotum, or if there are changes to the appearance of their penis, testicles or scrotum.
While problems that need surgery do not happen often, it is important to check so they can be ruled out.
Does my child need antibiotics?
Antibiotics are not usually needed for genital pain. Your healthcare provider may give oral antibiotics if they think your child has a UTI or antibiotic cream for BXO. Otherwise, most other causes of genital pain are treated with pain medicine or with a procedure.
Will my child need surgery?
A medical evaluation in the emergency department will determine if surgery is needed. If your child has testicular torsion, they will need surgery right away. Similarly, if a testicle is found to be damaged after a bad injury to the scrotum, surgery will also be needed. If a kidney stone is found, it is best if it passes on its own; however, if the pain is too much, your child is throwing up too much to stay hydrated or there is an infection, surgery might be needed.
Testicular torsion | Severe pain in one testicle Nausea/vomiting Abdominal pain Elevated and rotated testicle, possibly with swelling, redness & firmness | Go
immediately to the emergency department | Scrotal ultrasound showing no blood flow to testicle | Surgery to untwist the testicle |
Torsion of appendix testis | Severe pain in one testicle
Small blue bruise | Go to the emergency department to rule out testicular torsion | Scrotal ultrasound showing good blood flow to testicle, but no blood flow and swelling to the appendix testis
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Acetaminophen
Ibuprofen |
Epididymitis | Pain, redness, or swelling in one testicle or the other, tender to the touch. Can be associated with UTIs or STIs
| Go to the Emergency Department to rule out testicular torsion and a UTI or STI | Scrotal ultrasound showing increased blood flow to testicle | Acetaminophen Ibuprofen May need antibiotics
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Pelvic Floor Dysfunction
Constipation
Voiding Dysfunction | Pelvic or genital pain Difficulty urinating or stooling Urinary urgency/frequency | Discuss with your pediatrician for urology referral | History, physical exam | Pelvic floor physical therapy Constipation medicines Urinating every 2-3 hours |
Kidney stone | One-sided abdominal/side pain Scrotal pain Nausea or vomiting Blood in the urine Burning with urination/frequent urination | Go to the emergency department | Renal ultrasound vs. CT scan to find kidney stone | Acetaminophen Ibuprofen
Tamsulosin - or -
Surgery if UTI present/intractable vomiting/intolerable pain
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Facts to remember if your child has genital pain
Testicular torsion is when there is sudden severe pain in the testicle and needs to be checked immediately with an ultrasound in the emergency department. If not untwisted quickly, the testicle may not recover and will need to be removed.
Other causes for pain in one testicle are appendix testis torsion or epididymitis. These should be checked with an ultrasound to rule out testicular torsion, but they can usually just be treated with pain medicine
Pelvic floor dysfunction can affect normal pooping and peeing, causing pain in the pelvis, scrotum and with urination, as well as cause UTIs.
If your child has abdominal pain, nausea, vomiting, and/or blood in the urine, it might mean they are passing a kidney stone.
Foreskin problems can also cause pain but usually come with redness or swelling.
Many causes of genital pain can be treated with pain medicine. But it is important to have your child checked to find out what exactly is causing the pain.
More information
About Dr. Morin
 Jacqueline Morin, MD, is a pediatric urology fellow at Nationwide Children's Hospital. She has a special interest in penile reconstruction and robotic surgery in children. She completed her urology residency at the University of Kentucky and will complete her pediatric urology fellowship at Nationwide Children's Hospital. She currently serves on the AAP Section on Urology Education Committee.
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About Dr. Cheng
 Julie Cheng, MD, MAE, FAAP, is an assistant professor of urology at the University of Washington and Seattle Children’s Hospital in Seattle, WA. She is a member of the American Academy of Pediatrics Section on Urology. She is currently the co-chair of the Education Committee for the Section on Urology.
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