1 Do infants and toddlers get testicular torsion?

Neonates most frequently have extravaginal torsion (twisting above the tunica vaginalis), which usually occurs in utero and is more often associated with a nonviable testicle despite early discovery. Intravaginal testicular torsion (twisting of the spermatic cord within the tunica vaginalis) is most common in the second decade of life and is rare before the age of 10 years. Nevertheless, boys of any age with acute scrotal pain and swelling require prompt attention, probably radiologic evaluation, and possible surgical evaluation.

Pinto KJ, Noe HN, Jerkins GR: Management of neonatal testicular torsion. J Urol 158:1196–1197, 1997.

Stone KT, Kass EJ, Cacciarelli AA, Gibson DP: Management of suspected antenatal torsion: What is the best strategy? J Urol 153:782–784, 1995.

2 What are some of the important factors in the patient’s history that suggest testicular torsion?

Boys with testicular torsion will frequently report relatively sudden onset of unilateral scrotal pain, and they also may have nausea or vomiting. They may report that they had this pain on prior occasions, but that information does not argue against acute testicular torsion. Fever and painful voiding are uncommon. A history of trauma does not preclude, and can even predispose the patient to, torsion. It is important to recognize that the child with scrotal pathology often reports lower abdominal or groin pain. The patient reporting abdominal pain should always have a genital examination performed. Conversely, it is important to examine the abdomen of all patients with scrotal pain to evaluate peritoneal inflammation, intestinal obstruction, and abdominal masses.

Kamaledeen S, Surana R: Intermittent testicular pain: Fix the testes. BJU Int 91:406–408, 2003.

Lewis AG, Bukowski TP, Jarvis PD, et al: Evaluation of acute scrotum in the emergency department. J Pediatr Surg 30:277–282, 1995.

Seng YJ, Moissinac K: Trauma induced testicular torsion: A reminder for the unwary. Emerg Med J 17:381–382, 2000.

3 What is the “bell clapper deformity”?

Normally, the testicle is fixed to the posterior wall of the scrotum. Although it is almost impossible to detect this on physical examination, the majority of patients with testicular torsion have a congenital condition called the bell clapper deformity, whereby the tunica vaginalis completely envelopes the testicle. This allows the testicle and spermatic cord to twist in relation to the tunica vaginalis, compressing the vessels and nerves within. Although the deformity is bilateral, symptoms usually occur unilaterally. The left testicle is more commonly affected because the left spermatic cord is usually longer than the right.

4 What is manual detorsion?

In general, the prognosis is excellent if the testis is detorsed within 3 hours of symptom onset. Manual detorsion in the emergency setting can allow the testicle to remain viable until emergency surgery can be performed. Although the testicle can twist in either direction, it more commonly twists medially, toward the contralateral thigh. In the manual detorsion procedure, one holds the affected testicle between thumb and forefinger and untwists 360 degrees toward the ipsilateral thigh (Fig. 23-1). If relief is noted, the testicle should be rotated another 360° or more, since the usual twist is 720°. The direction can be reversed if more pain or swelling occurs after the initial maneuver. The trick is not to be shy or reserved while performing this procedure; it will hurt while it is being done, but if done correctly will greatly relieve symptoms almost immediately. Sedation and analgesia may be warranted to facilitate the detorsion procedure. Surgical correction (bilateral orchiopexy) is still necessary after this maneuver; however, the emergency detorsion procedure can help salvage the affected testicle.

Figure 23-1 Technique for manual detorsion of the testicle.

Cattolica EV: Preoperative manual detorsion of the torsed spermatic cord. J Urol 133:803–805, 1985.

Sessions AE, Rabinowitz R, Hulbert WC, et al: Testicular torsion: Direction, degree, duration and disinformation. J Urol 169:663–665, 2003.

5 How long will a torsed testicle be viable after the onset of pain?

Timing is crucial in the diagnosis and management of testicular torsion. In general, the prognosis is excellent if the testis is detorsed within 3 hours of symptom onset. Almost 100% of testes detorsed 3 hours after onset of symptoms will be viable. About 75% of testes detorsed after 8 hours, 10–20% of testes detorsed after 12 hours, and 0% of testes detorsed after 24 hours will be viable.

6 What is torsion of the appendix testis?

There are many appendages to the testis that are not functional but can certainly cause problems for younger children. The testicular appendix that is located on the superior pole of the testis is the most common appendage to twist on its pedicle and compromise vascular supply. This causes pain and swelling of the scrotum, albeit less so than testicular torsion. This occurs most often in school-aged children and early adolescents, and rarely in those over the age of 20 years. Nausea and vomiting are rare, and on physical examination the cremasteric reflex should be brisk unless swelling is severe. The diagnosis is more easily made if tenderness is located on the anterior and/or lateral pole of the testicle, or there is a “blue dot sign,” which signifies the appearance of a hemorrhagic appendix testis visible through the scrotal wall. If the diagnosis can be secured, torsion of the appendix testis is treated with oral analgesics and bedrest. The appendix will likely autoamputate, with no known sequelae.

Kadish HA, Bolte RG: A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 102:73–76, 1998.

7 What is the difference between epididymitis and orchitis, other than one being easier to spell?

Epididymitis is most often caused by infection. If the inflammation spreads to the testicles, the resulting epididymo-orchitis can be difficult to differentiate from primary orchitis. There are, however, some distinguishing features that can guide diagnosis. Fever, nausea, and vomiting are uncommon in patients with epididymitis. Conversely, orchitis is almost always due to a viral infection, and accompanies the other signs and symptoms of the specific virus, such as mumps. A history of urinary tract infections, penile discharge, or urologic abnormalities indicates the need for a workup for infectious causes of scrotal swelling. Epididymitis causes tenderness posteriorly and superiorly within the scrotum, whereas orchitis usually causes diffuse and often bilateral tenderness. Epididymitis can be due to Chlamydia trachomatis or Neisseria gonorrhea; however, prepubertal patients may be infected with gram-negative bacteria, such as Pseudomonas sp., Escherichia coli, or enterococci. The urinalysis is positive for white blood cells in less than one-third of patients with epididymitis and even less frequently in patients with orchitis.

Fein JA: Pathology in the privates: Acute scrotal swelling in children and adolescents. Pediatr Emerg Med Report 2:47–56, 1997.

8 Are there any rare entities causing scrotal pain or swelling that would be impressive to mention on rounds?

Some of the childhood vasculitides can cause scrotal swelling, including Henoch-Schönlein purpura (HSP), Kawasaki disease, and familial Mediterranean fever (FMF). Scrotal involvement occurs in approximately 30% of patients with HSP. Genital involvement usually follows the skin, joint, and intestinal symptoms by several days, and lasts up to 1 week. Surgical management is rarely necessary, but testicular torsion has rarely been noted to occur during the course of HSP.

Children with Kawasaki disease may report mild to moderate scrotal pain. The perineal rash involves the scrotal walls rather than the testicle, and usually accompanies the acute phase of the illness. Some patients with Kawasaki disease may have swelling of the epididymis as well.

In contrast to children with Kawasaki disease and HSP, children with FMF may report scrotal pain even before the final diagnosis is recognized. FMF is a genetic disease that affects Sephardic Jews, Turks, Armenians, and Middle Eastern Arabs. The illness is characterized by acute attacks of serositis, as well as the possibility of renal amyloidosis. Although rare in this disease, granulocytic infiltration can cause inflammation of the spermatic cord or the epididymis. Children report gradual onset of unilateral, red, painful scrotal swelling. They have fever, leukocytosis, and an elevated sedimentation rate.

Eshel G, Vinograd I, Barr J, Zemer D: Acute scrotal pain complicating familial Mediterranean fever in children. Br J Surg 81:894–896, 1994.

Hara Y, Tajiri T, Matsuura K, Hasegawa A: Acute scrotum caused by Henoch-Schönlein purpura. Int J Urol 11:578–580, 2004.

9 How can I differentiate among the variety of painless scrotal masses?

The most common painless scrotal masses are inguinal hernia, hydrocele, varicocele, spermatocele, and testicular tumor. Table 23-1 describes the features of each of these entities.

Skoog SJ: Benign and malignant pediatric scrotal masses. Pediatr Clin North Am 44:1229-1250, 1997.

10 Someday, somehow, every male will be kicked in the testicles. When do I worry about the patient who has this chief complaint?

Traumatic injuries to the testicle include, in order of increasing severity, contusion, hematoma, rupture, and dislocation. Physical examination should focus on the severity of swelling, the presence of both testicles inside the scrotal sac, and the relative size of each testicle. In general, the patient who has suffered recent scrotal trauma and who continues to report pain while in the emergency department setting deserves further evaluation. Similarly, patients with massive swelling of one or both sides of the scrotum require urgent urologic consultation. In general, these patients will require ultrasonography or surgical exploration to rule out testicle-threatening lesions. Ultrasonographic findings of testicular rupture may be subtle, and normal findings do not rule out this diagnosis. Patients in whom the pain resolves quickly and the physical examination is normal may be referred for follow-up, but need not undergo radiologic or surgical evaluation in the acute setting.

All males who suffer abdominal or pelvic trauma should undergo genital examination for concomitant injury. Absence of a testicle within the scrotum is concerning because patients with undescended testicles are at a higher risk for more severe testicular damage after blunt abdominal trauma.

Finally, it is important to remember that testicular torsion may follow minor trauma to the region, and this diagnosis must be considered for any patient with testicular pain regardless of the preceding history.

Micallef M, Ahmad I, Ramesh N, et al: Ultrasound features of blunt testicular injury. Injury 32:23–26, 2001.

Mulhall JP, Gabram SG, Jacobs LM: Emergency management of blunt testicular trauma. Acad Emerg Med 2:639–643, 1995