Acute scrotum

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Chapter 3 ACUTE SCROTUM

Theodore X. O’Connell

General Discussion

Every male patient with the acute onset of pain and swelling of the scrotum requires an immediate evaluation to diagnose or exclude testicular torsion. Of the cases of acute painful scrotum, 30% are caused by testicular torsion. Testicular torsion represents a true surgical emergency because the likelihood of testicular salvage decreases as the duration of torsion increases. The rate of testicular salvage is highest with symptoms 6 or fewer hours in duration. In children in whom the duration of symptoms is short and in whom clinical history and physical examination strongly suggest the diagnosis of acute testicular torsion, imaging studies may be bypassed in favor of surgical exploration.

The age of the child may help guide the evaluation. Testicular torsion may occur at any age but is more common during the newborn period and during early puberty. Appendiceal torsion and Henoch-Schönlein purpura are more common in prepubertal boys. Epididymitis is more common in adolescents and young adults.

The abrupt onset of severe pain is characteristic of testicular torsion. Mild to moderate pain that develops over several days is more suggestive of epididymitis or appendiceal torsion. An acute scrotal process may be referred to the abdomen, so any child presenting with an acute abdomen must have a complete genital examination.

Key Physical Findings

Assessment of degree of discomfort

Abdominal examination

Evaluation of the penis and scrotum to determine the degree and laterality of swelling, the presence and location of erythema, the lie of the testicles, and the degree of thickening of the scrotal skin

Evaluation of cremasteric reflex. The presence of an intact cremasteric reflex on the affected side indicates the absence of testicular torsion on that side

Examination of the inguinal canals for hernias, swelling, or erythema

Palpation of the testicles, beginning with the unaffected side

• Tenderness of the entire testicle is consistent with testicular torsion or orchitis

• Tenderness limited to the upper pole suggests appendiceal torsion, especially when associated with a hard, tender nodule in this area or a small bluish discoloration over the superior pole of the testicle

• Tenderness over the epididymis (which may be indurated) with a relatively nontender testicle suggests the presence of epididymitis

Skin examination for purpura

Suggested Work-up

Urinalysis	To evaluate for urinary tract infection. An abnormal urinalysis also may be present in a small number of boys with testicular torsion.
Emergent color Dopplerultrasound	If testicular torsion is considered but is not clear from the history and physical examination
Urgent surgical exploration	If testicular torsion is considered the likely diagnosis on the basis of the history and physical examination

Additional Work-up

Emergent surgical evaluation	If testicular torsion is found on color Doppler ultrasound on the basis of diminished or absent blood flow to the testicle
Urine culture	If epididymitis is suspected
Urethral culture for gonococcus and Chlamydia spp.	If urethral discharge is present
Radioisotope imaging	May be used as an alternative to color Doppler ultrasonography for the evaluation of testicular torsion but does not provide any anatomic data

1. Kass E.J., Lundak B. The acute scrotum. Pediatr Clin North Am. 1997;44:1251–1266.

2. Leslie J.A., Cain M.P. Pediatric urologic emergencies and urgencies. Pediatr Clin North Am. 2006;53:513–527.

3. Shalaby-Rana E., Lowe L.H., Blask A.N., Majd M. Imaging in pediatric urology. Pediatr Clin North Am. 1997;44:1065–1089.

4. Sheldon C.A. The pediatric genitourinary examination. Pediatr Clin North Am. 2001;48:1339–1380.

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