Acute Scrotum in Children

Background

• Acute scrotum refers to the sudden onset of scrotal pain, with or without swelling.
• Scrotal pain and swelling can be testicular or extratesticular in origin.
• The most common causes are testicular torsion, epididymitis/epididymo-orchitis, and torsion of the testicular appendage.
  • Testicular torsion is a urologic emergency, and must be excluded before considering other causes of acute scrotum.
  • Torsion of the testicular appendage typically affects prepubertal boys, while testicular torsion and epididymitis/epididymo-orchitis are more common in adolescents.
• Less common causes of acute scrotum include trauma, an incarcerated inguinoscrotal hernia, or a neoplasm.

Evaluation

• Evaluation of acute scrotum is directed toward determining the underlying cause, with initial focus on rapid identification of testicular torsion.
  • Suspect testicular torsion based on clinical presentation, which typically includes an acute onset of severe unilateral scrotal pain and swelling, often associated with nausea/vomiting. Other common features include a high-riding transversely oriented testicle and absent cremasteric reflex.
  • Doppler ultrasound is useful to evaluate acute scrotum, but should not delay intervention. (Clinical decisions should be based on physical exam.) (Strong recommendation)
• Clinical exam with or without ultrasonography is usually sufficient for diagnosing other underlying causes, but additional testing or surgical exploration may be needed.

Management

• Management depends on underlying cause, but all acute scrotums are presumed to be due to testicular torsion until proven otherwise.
• If clinical presentation suggests testicular torsion, obtain immediate Doppler ultrasound and urology consultation to consider urgent surgical exploration. Do not allow ultrasonography to delay urology consultation or surgical exploration (Strong recommendation).
• When clinical presentation suggests testicular torsion is unlikely:
  • If "blue dot" sign is present, consider conservative management and close follow-up for torsion of the testicular appendage.
  • If "blue dot" sign is absent, consider Doppler ultrasonography.
    • If testicular blood flow is decreased, obtain urology consultation to consider urgent surgical exploration for testicular torsion.
    • if blood flow is increased, consider conservative management or empiric antibiotics (depending on the suspected underlying cause) for epididymitis/epididymo-orchitis.
    • if incarcerated hernia is present, attempt manual reduction, followed by surgery.
• Scrotal trauma may require surgical repair, depending on the type and extent of injury