Last reviewed: 6 Nov 2021
Last updated: 01 Dec 2021



History and exam

Key diagnostic factors

  • presence of risk factors
  • age >19 years
  • unilateral scrotal pain and swelling of gradual onset
  • symptoms <6 weeks' duration
  • tenderness
  • hot, erythematous, swollen hemiscrotum
  • frequent and painful micturition
  • purulent urethral discharge

Other diagnostic factors

  • pyrexia
  • fluctuant swelling or induration of scrotal tissue
  • enlarged or tender prostate

Risk factors

  • unprotected sexual intercourse
  • bladder outflow obstruction
  • instrumentation of urinary tract
  • immunosuppression
  • vasculitis
  • amiodarone
  • mumps
  • exposure to tuberculosis (TB)

Diagnostic investigations

1st investigations to order

  • Gram stain of urethral secretions
  • urine dipstick test
  • urine microscopy
  • urine culture
  • nucleic acid amplification test (NAAT) of urethral secretions or first-void urine for Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium
  • culture of urethral secretions

Investigations to consider

  • colour duplex ultrasonography
  • surgical exploration
  • 3 early morning urine samples for acid-fast bacilli staining, culture, and nucleic acid amplification test for Mycobacterium tuberculosis
  • HIV test
  • syphilis test

Treatment algorithm



Ameeta E. Singh, BMBS(UK), MSc, FRCPC, FIDSA

Clinical Professor

Division of Infectious Diseases

University of Alberta




AES declares that she has no competing interests.


Dr Ameeta E. Singh would like to gratefully acknowledge Dr Hossein Sadeghi-Nejad, Dr Lorenzo DiGiorgio, Dr Mary Garthwaite, and Dr Ian Eardley, previous contributors to this topic.


HSN, LDG, and MG declare that they have no competing interests. IE is a consultant to Pfizer, Lilly, and Sanofi. He is a speaker for Lilly.

Peer reviewers

Sheldon Morris, MD, MPH

Assistant Professor

Division of Infectious Diseases

Department of Medicine

UCSD Antiviral Research Center

Division of Family Medicine

Department of Family and Preventive Medicine

UCSD La Jolla Family and Sports Medicine

San Diego



SM has received research funding support from NIH CHRP, CIRM, and Gilead Sciences. He has financial interests in Impact Biomedicines (now Celgene) and Forty Seven Inc. There is no conflict between these financial interests and any content in this topic.

Altaf Mangera, MBChB (Hons), MD, FRCS (Urol), FEBU

Consultant Urologist

Department of Urology

Royal Hallamshire Hospital




AM declares that he has no competing interests.

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