Overview
Definition:
Acute scrotum refers to a surgical emergency in pediatric patients characterized by sudden onset of severe scrotal pain, often accompanied by swelling and erythema
The two most critical differentials are testicular torsion and acute epididymitis, each requiring prompt and accurate diagnosis to prevent irreversible testicular damage.
Epidemiology:
Testicular torsion occurs most commonly in adolescents (ages 12-18) but can affect neonates and younger children, with an incidence of approximately 1 in 4,000 males per year
Acute epididymitis is more common in sexually active adolescents and adults but can occur in younger children, often associated with urinary tract infections or anatomical abnormalities.
Clinical Significance:
The primary clinical significance lies in the time-sensitive nature of testicular torsion
Irreversible testicular ischemia can occur within 4-6 hours, leading to testicular atrophy or loss
Distinguishing torsion from epididymitis is paramount, as torsion requires emergent surgical intervention, while epididymitis is managed medically.
Clinical Presentation
Symptoms:
Sudden onset of severe unilateral scrotal pain
Pain may radiate to the groin, lower abdomen, or flank
Nausea and vomiting are common, especially with torsion
Fever and dysuria may suggest epididymitis
History of trauma is less common but possible
A history of similar intermittent pain (intermittent torsion) may be present.
Signs:
Scrotal swelling, erythema, and tenderness are present in both conditions
In torsion, the testis is typically exquisitely tender, high-riding, and may lie in a horizontal lie
The cremasteric reflex is usually absent in torsion but present in epididymitis
A thickened, erythematous, and swollen scrotum with a palpable, enlarged, and tender epididymis is characteristic of epididymitis
Prehn's sign (pain relief with scrotal elevation) is often positive in epididymitis and negative in torsion, but this is not a reliable differentiator.
Diagnostic Criteria:
There are no strict diagnostic criteria
diagnosis relies on clinical suspicion, physical examination findings, and imaging
Urgent evaluation is indicated in all cases of acute scrotum
A high index of suspicion for testicular torsion is warranted in any child presenting with acute scrotal pain.
Diagnostic Approach
History Taking:
Detailed pain history: onset, duration, severity, character, radiation, exacerbating/alleviating factors
Associated symptoms: nausea, vomiting, fever, urinary symptoms
Previous episodes of scrotal pain or similar symptoms
History of trauma
Past medical history, including urinary tract issues or genitourinary anomalies.
Physical Examination:
Systematic examination of the scrotum, testes, epididymis, spermatic cord, and surrounding structures
Assess for swelling, erythema, tenderness, consistency, and position of testes
Palpate for the cremasteric reflex
Examine the abdomen for tenderness or masses
Assess for signs of systemic illness.
Investigations:
Doppler ultrasonography is the imaging modality of choice, highly sensitive and specific for testicular torsion, demonstrating reduced or absent testicular blood flow
Ultrasound may show an enlarged, hypoechoic testis with a heterogeneous echotexture and a thickened, edematous scrotum in torsion
In epididymitis, ultrasound typically shows an enlarged epididymis with increased blood flow on Doppler
Urinalysis with culture and sensitivity is essential to rule out UTI and guide antibiotic therapy in suspected epididymitis
A complete blood count may show leukocytosis
Nuclear scintigraphy (radionuclide imaging) is an alternative if ultrasound is equivocal, showing decreased radionuclide uptake in the torsed testis.
Differential Diagnosis:
Testicular torsion
Acute epididymitis
Torsion of a testicular appendage (Morgagni or Gartner's)
Fournier's gangrene (rare but life-threatening)
Incarcerated inguinal hernia
Trauma (hematoma, rupture)
Hydrocele
Varicocele
Orchitis
Appendiceal torsion is a self-limiting condition that can mimic torsion but often presents with a palpable blue-dot sign and may have normal or increased blood flow on Doppler
Necrotic appendiceal torsion may require surgical excision.
Management
Initial Management:
Immediate pain control with analgesics
Nausea and vomiting management with antiemetics
If testicular torsion is strongly suspected, emergent surgical exploration is indicated without delay
If epididymitis is suspected and torsion is unlikely, initiate appropriate antibiotic therapy.
Medical Management:
For suspected epididymitis in pediatric patients, management involves broad-spectrum antibiotics covering common pathogens (e.g., Ceftriaxone 250 mg IM and Azithromycin 1 g PO for sexually active adolescents
or Trimethoprim-sulfamethoxazole for younger children if UTI is confirmed)
Analgesics and anti-inflammatories for symptomatic relief
Scrotal support
Rest
Hydration
Follow-up for resolution.
Surgical Management:
Surgical exploration is the gold standard for suspected testicular torsion
The procedure involves detorsion of the testis, followed by orchiopexy (fixation of the torsed testis to the scrotal wall) to prevent recurrence
Contralateral orchiopexy is also performed to prevent torsion in the unaffected testis
Surgical exploration is also indicated if there is a high suspicion of appendiceal torsion with significant necrosis.
Supportive Care:
Close monitoring of vital signs and pain levels
Intravenous fluids if vomiting is severe or dehydration is present
Education for parents/guardians regarding the condition, treatment plan, and importance of follow-up
Post-operative wound care and pain management after surgical exploration.
Complications
Early Complications:
In testicular torsion: testicular infarction, testicular atrophy, infertility, testicular loss requiring orchiectomy
In epididymitis: abscess formation, chronic pain, infertility (rare).
Late Complications:
Infertility due to testicular damage or loss
Psychological impact of orchiectomy
Recurrent torsion if initial orchiopexy is inadequate
Chronic scrotal pain.
Prevention Strategies:
Prompt surgical intervention for suspected testicular torsion is the most critical preventive measure against testicular loss
Patient and parent education about the signs and symptoms of acute scrotum to seek immediate medical attention
Genetic counseling may be considered for individuals with a family history of testicular issues or cryptorchidism.
Prognosis
Factors Affecting Prognosis:
The most critical factor is the duration of ischemia
Testes salvaged within 4-6 hours of torsion have a good prognosis for survival
Delayed presentation significantly increases the risk of testicular loss and infertility
The degree of vascular compromise and the presence of comorbidities also influence prognosis.
Outcomes:
With timely diagnosis and surgical intervention for testicular torsion, testicular salvage rates are high
If torsion is not suspected and managed promptly, outcomes can range from testicular atrophy to complete loss
Epididymitis generally has a good prognosis with appropriate antibiotic treatment and supportive care, with resolution of symptoms usually occurring within weeks.
Follow Up:
Regular follow-up is essential after management of acute scrotum
For patients who underwent orchiopexy for torsion, monitor for recurrence and assess testicular size and function
For those with epididymitis, follow-up to ensure complete resolution of infection and symptoms, and to address any underlying etiologies like UTIs
Semen analysis may be considered in adolescents post-torsion or with risk factors for infertility.
Key Points
Exam Focus:
Always suspect testicular torsion in a child with acute scrotal pain
Absence of cremasteric reflex is a strong indicator of torsion
Doppler ultrasound is the investigation of choice
Time is testis – emergent surgical exploration is mandatory for suspected torsion
Differentiate from epididymitis based on history, exam, and imaging findings.
Clinical Pearls:
Do not rely solely on Prehn's sign for diagnosis
Even if the testis is descended, torsion can occur
A high index of suspicion is crucial, especially in neonates and adolescents
If in doubt, explore surgically
Treat suspected epididymitis promptly with appropriate antibiotics to prevent complications.
Common Mistakes:
Delaying surgical exploration for suspected testicular torsion due to misdiagnosis or indecision
Misinterpreting ultrasound findings
Treating suspected torsion as epididymitis without adequate investigation
Not performing contralateral orchiopexy during torsion surgery.