CSP is common and frustrating complaint of young adults. In this research, a large database was surveyed and the authors had full access to the long term outcome of the cases, so the risk of missing important diagnoses is low. To the best of our knowledge, this is the first large scale survey of CSP in young men in a primary care setting. It was found that CSP affects 0.8% of the young men. The mean primary physician’s number of visits was 5.3 with one patient visiting the clinic 37 times. Referrals to specialist in Urology were also common and the mean number of referrals was 1.4 per patient (range 1–11).
The etiologies of CSP in young men are reported in this study (Table 2). Varicocele was found in 54.6% of the patients and was more common among patients with longer duration of symptoms (up to 60.6% in group C). The prevalence of varicocele in normal young men estimated at 15–20%  and the prevalence of pain in individuals with varicocele is estimated between approximately 2 and 10% , which mean estimated prevalence of painful varicocele of 0.3–2% in normal young men population. We found that painful varicocele was found in 0.4% of normal young men population which is close to the expected rate.
According to Granitsiotis et al. nearly 25% of patients with chronic orchialgia have no obvious cause for the pain . In our study, no specific etiology could be established in 1062 patients (34.4%). The percentage of patients with idiopathic scrotal pain dropped with longer symptom duration. This may suggests that in patients with idiopathic scrotal pain who complain for longer periods of time, further evaluations were done and in most cases, varicocele was found and diagnosed as the presumed cause of the symptoms.
The prevalence of the other diagnoses was quite similar between the different time groups from the shortest duration of pain (15–29 days—group A) to longest (more than 60 days—group C). This challenges the historic definition of CSP as pain lasting more than 90 days that is based on a study of 45 patients . Therefore, we suggest defining CSP as an intermittent or constant testicular pain lasting for more 14 days that interferes significantly with the patient’s daily activities.
Diagnosis of scrotal pain due to scrotal skin lesions, torsion–detorsion syndrome, scrotal trauma, scrotal tumor or nephrolithiasis were assigned in about 1% of patients or less, probably because these etiologies are of acute manifestation or because of the painless nature of these pathologies. A total of 252 (8.2%) patients underwent surgical interventions including: hernia surgery in 46 patients (1.5%) and varicocele and/or hydrocele repair in 206 patients (6.7%). The rates of varicocele and/or hydrocele surgery were higher in group C, probably because of failure of conservative treatments.
The management of CSP depends on the cause or presumed etiology of the testicular pain. The key to successful assessment remains the history and physical examination and early use of ultrasound of testes and inguinal region is the most reliable imaging modality in the management of chronic testicular pain. Lau et al. observed that in patients with testicular pain longer than 14 days, sonography detected lesions in 28% of patients with no clinical findings on examination including varicocele, hydrocele, epididymal thickening and epididymal cyst . Thus, we suggest early referral to ultrasonography of the testes and inguinal region for all patients with CSP.
Testicular torsion (TT) is a relatively rare urological emergency in which the diagnosis must be made accurately and rapidly to prevent loss of testicular function. TT is a medical situation of an acute presentation. However, TT may occur in patients with CSP. In current study, 25.9% of the patients visit at least once in the ED, in most cases because of physicians’ suspicious of TT. Yet TT and torsion of the appendix testes were not found in any of the patients and only 1.0% of the patients were hospitalized emergently for any reason.