Medicine is a personal and ever changing science where providers of medical care have a responsibility to use the most recent and reliable information to guide their patients. Curbside allows medical providers to create and distribute clinical pathways to improve the care provided at their institutions. However, there is the constant potential for human error, changes in medical sciences or patient specific variables that may not be taken into account in these pathways. Therefore, Curbside cannot warrant that the information contained in these resources is accurate or complete and are not responsible for any errors or omissions or for the results obtained from the use of this information. All users of Curbside should confirm the information provided here with other trusted sources and consult with expert health providers before making any health care decision.
Scrotal pain in a boy is an emergent condition that needs to be evaluated promptly. Initial evaluation should focus on characterizing the pain, trauma, change in urination/hematuria, sexual activity and fever. Physical exam findings may lead to increased probability of diseases, however, these signs are poorly reliable and present in multiple disease processes.
Testicular torsion is an emergent condition that requires prompt evaluation and surgical management. Torsion usually is secondary to a inadequate fixation of the testis to the tunica vaginalis ("Bell Clapper Deformity"). This allows the testis to twist on the spermatic cord causing ischemia to the tesis. 65% of cases occur in boys between 12 - 18 years.
Most cases present in less than 12 hours' duration. 90% have nausea/vomiting. Torsion may also present with intermittent pain although it can be much more difficult to diagnosis (US only 75% sensitive for intermittent torsion).
Ultrasound is the imaging modality of choice for evaluation of acute pathologic diseases of the scrotum. For testicular torsion it has a sensitivity of 69 - 100% and specificity of 77 - 100%. It's sensitivity for intermittent testicular torsion is lower, ~70%.
In cases of testicular torsion, manual detorsion has been associated with increased salvage rate (97% vs. 75%). When surgical intervention is going to be delayed it is usually pertinent to attempt manual detorsion.
Non-testicluar torsion (appendix testis or appendix epididymis) in the scrotum is a common finding in young males (most commonly 7 - 12 years). In addition it has many of the similar clinical findings of testicular torsion which is difficult to exclude without ultrasound findings. Treatment for non-testicular torsion is supportive unless the pain is severe and persistnat for more than 5 to 10 days.
Epididymitis commonly occurs in post-pubertal boys, usually related to an STI, however, it also may occur in non-sexually active individuals. In these patients, bacterial infections are often associated with urinary tract abnormalities, but most cases were non-bacterial, but more commonly Mycoplasma pneumoniae, enteroviruses, or adenoviruses. In post-pubertal boys empiric treatment is warranted in most cases. Given the low risk of bacterial infection in pre-pubescent boys they should be recommended scrotal support, rest and NSAIDs.
Orchitis is unlikely to be bacterial in origin (rubella, mumps, coxsackie, echovirus, lymphocytic choriomeningitis virus and parvovirus) and treatment is supportive (scrotal support, rest and NSAIDs.)