Acute Scrotal/Testicular Pain (6 mo - 18 years) - Curbside
Acute Scrotal/Testicular Pain (6 mo - 18 years)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Acute constant or intermittent scrotal/testicular pain
Exclusion Criteria
  • Traumatic injury
  • History of complex urology surgery/abnormalities
  • Painless scrotal swelling

Consider urology consult

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Evidence
Total Notes: 6
Evidence

1 Scrotal pain

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.



References:
  1. The management of acute testicular pain in children and adolescents.
    Jefferies MT, Cox AC, Gupta A, Proctor A,
    BMJ 2015 Apr;350:h1563.
  2. Testicular torsion versus epididymitis: a diagnostic challenge.
    Petrack EM, Hafeez W,
    Pediatr Emerg Care 1992 Dec;8(6):347-50.
  3. The incidence of the cremasteric reflex in normal boys.
    Caesar RE, Kaplan GW,
    J. Urol. 1994 Aug;152(2 Pt 2):779-80.
  4. The importance of the cremasteric reflex in acute scrotal swelling in children.
    Rabinowitz R,
    J. Urol. 1984 Jul;132(1):89-90.
  5. Evaluation of acute scrotum in the emergency department.
    Lewis AG, Bukowski TP, Jarvis PD, Wacksman J, Sheldon CA,
    J. Pediatr. Surg. 1995 Feb;30(2):277-81; discussion 281-2.

2 Testicular Torsion

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).



References:
  1. Evaluation of acute scrotum in the emergency department.
    Lewis AG, Bukowski TP, Jarvis PD, Wacksman J, Sheldon CA,
    J. Pediatr. Surg. 1995 Feb;30(2):277-81; discussion 281-2.
  2. The acute scrotum.
    Edelsberg JS, Surh YS,
    Emerg. Med. Clin. North Am. 1988 Aug;6(3):521-46.
  3. The acute scrotum.
    Kass EJ, Lundak B,
    Pediatr. Clin. North Am. 1997 Oct;44(5):1251-66.
  4. Acute diseases of the scrotum.
    Tumeh SS, Benson CB, Richie JP,
    Semin. Ultrasound CT MR 1991 Apr;12(2):115-30.
  5. Torsion of the testis and allied conditions.
    Williamson RC,
    Br J Surg 1976 Jun;63(6):465-76.
  6. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages.
    Kadish HA, Bolte RG,
    Pediatrics 1998 Jul;102(1 Pt 1):73-6.
  7. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys.
    Karmazyn B, Steinberg R, Kornreich L, Freud E, Grozovski S, Schwarz M, Ziv N, Livne P,
    Pediatr Radiol 2005 Mar;35(3):302-10.
  8. Testicular torsion versus epididymitis: a diagnostic challenge.
    Petrack EM, Hafeez W,
    Pediatr Emerg Care 1992 Dec;8(6):347-50.
  9. Pediatric testicular problems.
    Pillai SB, Besner GE,
    Pediatr. Clin. North Am. 1998 Aug;45(4):813-30.
  10. Acute scrotal swelling in children.
    Caldamone AA, Valvo JR, Altebarmakian VK, Rabinowitz R,
    J. Pediatr. Surg. 1984 Oct;19(5):581-4.
  11. The importance of the cremasteric reflex in acute scrotal swelling in children.
    Rabinowitz R,
    J. Urol. 1984 Jul;132(1):89-90.
  12. The cremasteric reflex: a useful but imperfect sign in testicular torsion.
    Nelson CP, Williams JF, Bloom DA,
    J. Pediatr. Surg. 2003 Aug;38(8):1248-9.
  13. The incidence of the cremasteric reflex in normal boys.
    Caesar RE, Kaplan GW,
    J. Urol. 1994 Aug;152(2 Pt 2):779-80.
  14. The management of acute testicular pain in children and adolescents.
    Jefferies MT, Cox AC, Gupta A, Proctor A,
    BMJ 2015 Apr;350:h1563.
  15. Intermittent testicular torsion.
    Stillwell TJ, Kramer SA,
    Pediatrics 1986 Jun;77(6):908-11.
  16. Intermittent testicular torsion: diagnostic features and management outcomes.
    Eaton SH, Cendron MA, Estrada CR, Bauer SB, Borer JG, Cilento BG, Diamond DA, Retik AB, Peters CA,
    J. Urol. 2005 Oct;174(4 Pt 2):1532-5; discussion 1535.
  17. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis.
    Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ,
    AJR Am J Roentgenol 2013 Oct;201(4):912-8.

3 Scrotal Ultrasound

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%.



References:
  1. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis.
    Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ,
    AJR Am J Roentgenol 2013 Oct;201(4):912-8.
  2. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys.
    Karmazyn B, Steinberg R, Kornreich L, Freud E, Grozovski S, Schwarz M, Ziv N, Livne P,
    Pediatr Radiol 2005 Mar;35(3):302-10.
  3. Intermittent testicular torsion.
    Stillwell TJ, Kramer SA,
    Pediatrics 1986 Jun;77(6):908-11.
  4. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages.
    Kadish HA, Bolte RG,
    Pediatrics 1998 Jul;102(1 Pt 1):73-6.
  5. Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality?
    Lam WW, Yap TL, Jacobsen AS, Teo HJ,
    Pediatr Radiol 2005 Jun;35(6):597-600.
  6. Acute scrotal symptoms in boys with an indeterminate clinical presentation: comparison of color Doppler sonography and scintigraphy.
    Paltiel HJ, Connolly LP, Atala A, Paltiel AD, Zurakowski D, Treves ST,
    Radiology 1998 Apr;207(1):223-31.
  7. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion.
    Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG,
    Pediatrics 2000 Mar;105(3 Pt 1):604-7.
  8. Accuracy of Doppler sonography in the evaluation of acute conditions of the scrotum in children.
    Yazbeck S, Patriquin HB,
    J. Pediatr. Surg. 1994 Sep;29(9):1270-2.
  9. Do all children with an acute scrotum require exploration?
    Kass EJ, Stone KT, Cacciarelli AA, Mitchell B,
    J. Urol. 1993 Aug;150(2 Pt 2):667-9.
  10. Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain.
    Nussbaum Blask AR, Bulas D, Shalaby-Rana E, Rushton G, Shao C, Majd M,
    Pediatr Emerg Care 2002 Apr;18(2):67-71.

4 Manual detorsion

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.



References:
  1. Preoperative manual detorsion of the spermatic cord with Doppler ultrasound monitoring in patients with intravaginal acute testicular torsion.
    Garel L, Dubois J, Azzie G, Filiatrault D, Grignon A, Yazbeck S,
    Pediatr Radiol 2000 Jan;30(1):41-4.
  2. Manual derotation of the twisted spermatic cord.
    Cornel EB, Karthaus HF,
    BJU Int. 1999 Apr;83(6):672-4.
  3. Improving Organ Salvage in Testicular Torsion: Comparative Study of Patients Undergoing vs Not Undergoing Preoperative Manual Detorsion.
    Dias Filho AC, Oliveira Rodrigues R, Riccetto CL, Oliveira PG,
    J. Urol. 2017 Mar;197(3 Pt 1):811-817.
  4. Testicular torsion: direction, degree, duration and disinformation.
    Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA,
    J. Urol. 2003 Feb;169(2):663-5.

5 Torsion of the appendix testis or appendix epididymis

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.



References:
  1. The acute paediatric scrotum.
    Fisher R, Walker J,
    Br J Hosp Med;51(6):290-2.
  2. The acute scrotum.
    Kass EJ, Lundak B,
    Pediatr. Clin. North Am. 1997 Oct;44(5):1251-66.
  3. Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children.
    Boettcher M, Bergholz R, Krebs TF, Wenke K, Treszl A, Aronson DC, Reinshagen K,
    Urology 2013 Oct;82(4):899-904.
  4. Scrotal emergencies.
    Baldisserotto M,
    Pediatr Radiol 2009 May;39(5):516-21.
  5. The pattern of radionuclide scrotal scan in torsion of testicular appendages.
    Melloul M, Paz A, Lask D, Luttwak Z, Mukamel E,
    Eur J Nucl Med 1996 Aug;23(8):967-70.
  6. The acute scrotum.
    Edelsberg JS, Surh YS,
    Emerg. Med. Clin. North Am. 1988 Aug;6(3):521-46.
  7. Pediatric testicular problems.
    Pillai SB, Besner GE,
    Pediatr. Clin. North Am. 1998 Aug;45(4):813-30.
  8. Acute scrotal pain and swelling in children: a surgical emergency.
    Flanigan RC, DeKernion JB, Persky L,
    Urology 1981 Jan;17(1):51-3.

6 Epididymis and Orchitis

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.)

 



References:
  1. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages.
    Kadish HA, Bolte RG,
    Pediatrics 1998 Jul;102(1 Pt 1):73-6.
  2. Pediatric testicular problems.
    Pillai SB, Besner GE,
    Pediatr. Clin. North Am. 1998 Aug;45(4):813-30.
  3. Acute epididymitis and urinary tract anomalies in children.
    Merlini E, Rotundi F, Seymandi PL, Canning DA,
    Scand. J. Urol. Nephrol. 1998 Jul;32(4):273-5.
  4. Epididymitis in infants and boys: underlying urogenital anomalies and efficacy of imaging modalities.
    Siegel A, Snyder H, Duckett JW,
    J. Urol. 1987 Oct;138(4 Pt 2):1100-3.
  5. Epididymitis in children and adolescents. A 20-year retrospective study.
    Likitnukul S, McCracken GH, Nelson JD, Votteler TP,
    Am. J. Dis. Child. 1987 Jan;141(1):41-4.
  6. Acute epididymitis in boys: evidence of a post-infectious etiology.
    Somekh E, Gorenstein A, Serour F,
    J. Urol. 2004 Jan;171(1):391-4; discussion 394.
  7. Are antibiotics necessary for pediatric epididymitis?
    Santillanes G, Gausche-Hill M, Lewis RJ,
    Pediatr Emerg Care 2011 Mar;27(3):174-8.
  8. The acute scrotum.
    Kass EJ, Lundak B,
    Pediatr. Clin. North Am. 1997 Oct;44(5):1251-66.
  9. Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children.
    Boettcher M, Bergholz R, Krebs TF, Wenke K, Treszl A, Aronson DC, Reinshagen K,
    Urology 2013 Oct;82(4):899-904.
  10. Testicular torsion versus epididymitis: a diagnostic challenge.
    Petrack EM, Hafeez W,
    Pediatr Emerg Care 1992 Dec;8(6):347-50.
  11. Scrotal emergencies.
    Baldisserotto M,
    Pediatr Radiol 2009 May;39(5):516-21.
  12. Management of acute scrotum in children--the impact of Doppler ultrasound.
    Schalamon J, Ainoedhofer H, Schleef J, Singer G, Haxhija EQ, Höllwarth ME,
    J. Pediatr. Surg. 2006 Aug;41(8):1377-80.
  13. Sexually transmitted diseases treatment guidelines, 2015.
    Workowski KA, Bolan GA, Bolan GA,
    MMWR Recomm Rep 2015 Jun;64(RR-03):1-137.
  14. Acute epididymitis in boys: are antibiotics indicated?
    Lau P, Anderson PA, Giacomantonio JM, Schwarz RD,
    Br J Urol 1997 May;79(5):797-800.
  15. The genitalia
    Green MG.
    Pediatric Diagnosis: Interpretatino of Symptoms and Signs in Children and Adolescents, 6th WB Saunders, Philadelphia 1998. p.101.